| Certificate Number | - | | Date Issued |
| Child Given Name | |
Adams | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Gus. |
Amlund | Father's Surname |
| Father's Occupation | Blacksmith | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 34 | Father's Age |
| Mother's Given Name | Mattie | Trlifotottes | Mother's Maiden Name |
| Mother's Surname | Amlund | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 33 | 3 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |