| Certificate Number | 239 | | Date Issued |
| Child Given Name | |
Swan | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Jul 1889 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | John |
Swan | Father's Surname |
| Father's Occupation | Banker | | Father's Nationality |
| Father's Birth Place | Sweden | 48 | Father's Age |
| Mother's Given Name | Emma R. | Mitabel | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Jones Co IA | Mother's Birth Place |
| Mother's Age | 40 | 4 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |