| Certificate Number | 3 | | Date Issued |
| Child Given Name | |
Swanson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Sep 1884 |
Boone Co IA | Place of Birth |
| Father's Given Name | William |
Swanson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Sweden | 38 | Father's Age |
| Mother's Given Name | Lizzie M. | Sadistrum | Mother's Maiden Name |
| Mother's Surname | Swanson | Boone Co IA | Mother's Residence |
| Mother's Nationality | | Sweden | Mother's Birth Place |
| Mother's Age | 26 | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | E.B. Plumb M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | E.B. Plumb M.D. | | |