| Certificate Number | 91 | | Date Issued |
| Child Given Name | |
Dale | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 Jan 1890 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Tom |
Dale | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Norway | 36 | Father's Age |
| Mother's Given Name | Elen | Erikson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 35 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Peterson | Story City IA | Medical Attendant's Address |