| Certificate Number | 177 | | Date Issued |
| Child Given Name | Ine |
Brattebo | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 May 1888 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | O.T. |
Brattebo | Father's Surname |
| Father's Occupation | Livery | | Father's Nationality |
| Father's Birth Place | Norway | 23 | Father's Age |
| Mother's Given Name | G.O. | Bergen | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | John Emmet | Story City IA | Medical Attendant's Address |