| Certificate Number | 150 | | Date Issued |
| Child Given Name | |
Dorsland | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Jul 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Thomas |
Dorsland | Father's Surname |
| Father's Occupation | Sec. Hand NW. R.R. | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 33 | Father's Age |
| Mother's Given Name | Anna Thompson | Thompson | Mother's Maiden Name |
| Mother's Surname | Dorsland | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |