| Certificate Number | 135 | | Date Issued |
| Child Given Name | |
Christensen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Mar 1889 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | C.N. |
Christenson | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | Norway | 28 | Father's Age |
| Mother's Given Name | Christine | Peterson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Peterson | Story City IA | Medical Attendant's Address |