| Certificate Number | 356 | | Date Issued |
| Child Given Name | Severt Olai |
Britson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Sep 1889 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Brit J. |
Britson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | America | 33 | Father's Age |
| Mother's Given Name | Mary E. | Howe | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Bretha Skogerboe | Roland IA | Medical Attendant's Address |