| Certificate Number | 433 | | Date Issued |
| Child Given Name | Karl Johan |
Sampson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Sep 1986 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Sam |
Sampson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 37 | Father's Age |
| Mother's Given Name | Regina | Halvorson | Mother's Maiden Name |
| Mother's Surname | Sampson | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 35 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Fanny McClain | McCallsburg IA | Medical Attendant's Address |
| Certificate Signer's Name | Fanny McClain | McCallsburg IA | Certificate Signer's Address |
| Returned by Name | Fanny McClain | | |