| Certificate Number | 166 | | Date Issued |
| Child Given Name | |
Tollefson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Apr 1885 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Louis |
Tollifson | Father's Surname |
| Father's Occupation | Painter | | Father's Nationality |
| Father's Birth Place | Norway | 24 | Father's Age |
| Mother's Given Name | Mary | Olson | Mother's Maiden Name |
| Mother's Surname | Tollifson | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |