| Certificate Number | 98 | | Date Issued |
| Child Given Name | |
Rod | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 13 Feb 1889 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Erik M. |
Rod | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | Norway | 28 | Father's Age |
| Mother's Given Name | Julia | Jacobson | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 28 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Martine Birkeland | Roland IA | Medical Attendant's Address |