| Certificate Number | 286 | | Date Issued |
| Child Given Name | |
Wasnick | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Jan 1886 |
| Place of Birth |
| Father's Given Name | Orin |
Wasnick | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 39 | Father's Age |
| Mother's Surname | | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 33 | 7 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |