| Certificate Number | 285 | | Date Issued |
| Child Given Name | |
Stole | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 14 Nov 1881 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Osman |
Stole | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 35 | Father's Age |
| Mother's Given Name | Mary | Peterson | Mother's Maiden Name |
| Mother's Surname | Stole | | Mother's Residence |
| Mother's Nationality | American | Rock Co WI | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |