| Certificate Number | 219 | | Date Issued |
| Child Given Name | Dorthea |
Bonde | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 May 1889 |
Howard Twp Story Co IA | Place of Birth |
| Father's Given Name | Jens R. |
Bonde | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 45 | Father's Age |
| Mother's Given Name | Dorthea | Hansen | Mother's Maiden Name |
| Mother's Surname | | Howard Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 42 | 11 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Peterson | Story City IA | Medical Attendant's Address |
| Returned by Name | O. Ostrem | | |