| Certificate Number | 245 | | Date Issued |
| Child Given Name | |
Willard | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Nov 1885 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | B.C.T. |
Willard | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Denmark | 35 | Father's Age |
| Mother's Given Name | Margaret | Severson | Mother's Maiden Name |
| Mother's Surname | Willard | Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |