| Certificate Number | 270 | | Date Issued |
| Child Given Name | |
Tesdal | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 10 Nov 1891 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Julius |
Tesdal | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Michigan | 31 | Father's Age |
| Mother's Given Name | Mariah | Mead | Mother's Maiden Name |
| Mother's Surname | Tesdal | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Mead | Richland Twp IA | Medical Attendant's Address |
| Certificate Signer's Name | Julius, father Tesdal | | Certificate Signer's Address |
| Returned by Name | Julius, father Tesdal | | |