| Certificate Number | 1019 | | Date Issued |
| Child Given Name | Martha S. |
Simonson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Sep 1884 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Simonson | Father's Surname |
| Father's Occupation | Farming | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 20 | Father's Age |
| Mother's Given Name | Halverine | Sorenson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | John Emmet | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | John Emmet | Story City IA | Certificate Signer's Address |
| Returned by Name | John Emmet | | |