| Certificate Number | 25 | | Date Issued |
| Child Given Name | |
Burrets | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Nov 1889 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | J.F. |
Burrets | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Norway | 35 | Father's Age |
| Mother's Given Name | Caroline | Sheldahl | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 28 | 5 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlain | Nevada IA | Medical Attendant's Address |