| Certificate Number | 50 | | Date Issued |
| Child Given Name | Martin |
Severtson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Nov 1884 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Severt J. |
Severtson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 29 | Father's Age |
| Mother's Given Name | Arble | Sheldahl | Mother's Maiden Name |
| Mother's Surname | Severtson | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hays | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hays | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hays | | |