| Certificate Number | 19 | | Date Issued |
| Child Given Name | Lars |
Dale | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Oct 1887 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Thomas |
Dale | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Norway | 34 | Father's Age |
| Mother's Given Name | Lena | Haigstoil | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 34 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Annie Tokheim | Story City IA | Medical Attendant's Address |