| Certificate Number | 191 | | Date Issued |
| Child Given Name | Jonas |
Traavas | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Aug 1890 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Jonas |
Traavas | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Norway | 39 | Father's Age |
| Mother's Given Name | Anna | Pederson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 43 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Anna G. Hakerin | Story City IA | Medical Attendant's Address |