| Certificate Number | 455 | | Date Issued |
| Child Given Name | Clare Rebecca |
Apland | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Sep 1886 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Knute O. |
Apland | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Iowa | 27 | Father's Age |
| Mother's Given Name | Tomenia | Erickson | Mother's Maiden Name |
| Mother's Surname | Apland | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 22 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |