| Certificate Number | 11 | | Date Issued |
| Child Given Name | Julius |
Christenson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Nov 1891 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Christ |
Christenson | Father's Surname |
| Father's Occupation | Shoe Maker | | Father's Nationality |
| Father's Birth Place | Norway | 54 | Father's Age |
| Mother's Given Name | Martha | Olson | Mother's Maiden Name |
| Mother's Surname | Christenson | | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 40 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Tolkhiem | Story City IA | Medical Attendant's Address |