| Certificate Number | 395 | | Date Issued |
| Child Given Name | Andrew |
Waldemar | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Jun 1886 |
Onondago St Ames Story Co IA | Place of Birth |
| Father's Given Name | Martin |
Henricksen | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Denmark | 26 | Father's Age |
| Mother's Given Name | Mary | Jensen | Mother's Maiden Name |
| Mother's Surname | Henrickson | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |