| Certificate Number | 563 | | Date Issued |
| Child Given Name | Germania |
Sheveland | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Bert |
Sheveland | Father's Surname |
| Father's Occupation | Coal heaver | | Father's Nationality |
| Father's Birth Place | Norway | 27 | Father's Age |
| Mother's Given Name | Christina | Erasmusson | Mother's Maiden Name |
| Mother's Surname | Sheveland | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 30 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Erasmesson | | Medical Attendant's Address |
| Returned by Name | J.M. Brown | | |