| Certificate Number | 314 | | Date Issued |
| Child Given Name | |
Tesdall | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | O.C. |
Tesdall | Father's Surname |
| Father's Occupation | Farming | | Father's Nationality |
| Father's Birth Place | Norway | 49 | Father's Age |
| Mother's Given Name | Betsey | Sheldall | Mother's Maiden Name |
| Mother's Surname | | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 43 | 13 | Number of Child This Mother |
| Medical Attendant's Name | Malinda Arent | Huxley IA | Medical Attendant's Address |
| Certificate Signer's Name | O.C. Tesdall | Huxley IA | Certificate Signer's Address |
| Returned by Name | O.C. Tesdall | | |