| Certificate Number | 453 | | Date Issued |
| Child Given Name | |
Severtson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Sep 1882 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Samuel Smith |
Severtson | Father's Surname |
| Father's Occupation | Farmer | Scandinavian | Father's Nationality |
| Father's Birth Place | Wisconson | 23 | Father's Age |
| Mother's Given Name | Elizabeth | Wills | Mother's Maiden Name |
| Mother's Surname | Severtson | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |