| Certificate Number | 78 | | Date Issued |
| Child Given Name | |
Tjernagle | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Jan 1888 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | L.J. |
Tjernagel | Father's Surname |
| Father's Occupation | Banker | | Father's Nationality |
| Father's Birth Place | Illinois | 25 | Father's Age |
| Mother's Given Name | Sarah | Johnson | Mother's Maiden Name |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 36 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Anna G. Tokheim | Story City IA | Medical Attendant's Address |