| Certificate Number | 583 | | Date Issued |
| Child Given Name | Thomas |
Reinertson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Mar 1883 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Anton |
Reinertson | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 25 | Father's Age |
| Mother's Given Name | Emma | Severson | Mother's Maiden Name |
| Mother's Surname | Reinertson | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |