| Child Given Name | Iver D. |
Sampson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Apr 1882 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Iver |
Sampson | Father's Surname |
| Father's Occupation | Farming | | Father's Nationality |
| Father's Birth Place | Norway | 39 | Father's Age |
| Mother's Given Name | Julia | Thompson | Mother's Maiden Name |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 39 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Ingeborg, Mrs. Rygh | | Medical Attendant's Address |
| Certificate Signer's Name | Sam I. Sampson | | Certificate Signer's Address |