| Certificate Number | 224 | | Date Issued |
| Child Given Name | |
Severtson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 Aug 1889 |
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 | 34 | Father's Age |
| Mother's Given Name | Arabel | Sheldahl | Mother's Maiden Name |
| Mother's Surname | | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 32 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |