| Certificate Number | 279 | | Date Issued |
| Child Given Name | Albert |
Rasmuson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Jan 1886 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Rasmus |
Rasmuson | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Denmark | 23 | Father's Age |
| Mother's Given Name | Lansena J. | Peterson | Mother's Maiden Name |
| Mother's Surname | Rasmuson | | Mother's Residence |
| Mother's Nationality | | Germany | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |