| Certificate Number | 197 | | Date Issued |
| Child Given Name | |
Thompson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Aug 1890 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Thompson |
Thompson | Father's Surname |
| Father's Occupation | Cole heaver | | Father's Nationality |
| Father's Birth Place | Norway | 30 | Father's Age |
| Mother's Given Name | Sarah | Olson | Mother's Maiden Name |
| Mother's Surname | | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |