| Certificate Number | 218 | | Date Issued |
| Child Given Name | |
Samuelson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Sheldahl Story Co IA | Place of Birth |
| Father's Given Name | A. Gust. |
Samuelson | Father's Surname |
| Father's Occupation | Engineer | | Father's Nationality |
| Father's Birth Place | | 27 | Father's Age |
| Mother's Given Name | Lottie | Peterson | Mother's Maiden Name |
| Mother's Surname | Samuelson | Sheldahl Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 29 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Jer. A. Anderson | Sheldahl IA | Medical Attendant's Address |
| Certificate Signer's Name | Jer. A. Anderson | Sheldahl IA | Certificate Signer's Address |
| Returned by Name | Jer. A. Anderson | | |