| Certificate Number | 63 | | Date Issued |
| Child Given Name | Selmer |
Sorenson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Jan 1885 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Soren |
Sorenson | Father's Surname |
| Father's Occupation | General Worker | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 32 | Father's Age |
| Mother's Given Name | Parnella | Monson | Mother's Maiden Name |
| Mother's Surname | Sorenson | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 33 | 7 | 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 | | |