| Certificate Number | 88 | | Date Issued |
| Child Given Name | |
Severson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Jan 1888 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Sam'l |
Severson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 39 | Father's Age |
| Mother's Given Name | M.E. | Wills | Mother's Maiden Name |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | A.S. Aplin | Cambridge IA | Medical Attendant's Address |