| Certificate Number | 101 | | Date Issued |
| Child Given Name | |
Cue | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Feb 1890 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Martin |
Cue | Father's Surname |
| Father's Occupation | R.R. Agt | | Father's Nationality |
| Father's Birth Place | Pala IA | 25 | Father's Age |
| Mother's Given Name | Nea | Christensen | 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 | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Peterson | Story City IA | Medical Attendant's Address |