| Certificate Number | 130 | | Date Issued |
| Child Given Name | |
Christensen | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 25 Feb 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Lars N. |
Christensen | Father's Surname |
| Father's Occupation | Clerk in store | Norwegian | Father's Nationality |
| Father's Birth Place | Parish of Thorness Norway | 33 | Father's Age |
| Mother's Given Name | Sarah E. | Britson | Mother's Maiden Name |
| Mother's Surname | Christian | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Kendall Co IL | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |