| Certificate Number | 551 | | Date Issued |
| Child Given Name | Tina Serena |
Sheveland | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Jan 1883 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Bert F. |
Sheveland | Father's Surname |
| Father's Occupation | Rail Roader | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 24 | Father's Age |
| Mother's Given Name | Christina | Erasmason | Mother's Maiden Name |
| Mother's Surname | Sheveland | Cambridge Story IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Martha E. Ferguson | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | Martha E. Ferguson | Cambridge IA | Certificate Signer's Address |
| Returned by Name | Martha E. Ferguson | | |