| Certificate Number | 567 | | Date Issued |
| Child Given Name | Annie |
Shefeland | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Jan 1883 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Osmon O. |
Shefeland | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 29 | Father's Age |
| Mother's Given Name | Regana | Johnson | Mother's Maiden Name |
| Mother's Surname | Shefeland | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |