| Certificate Number | 99 | | Date Issued |
| Child Given Name | |
Ericksen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Dec 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Mandins Severin |
Ericksen | Father's Surname |
| Father's Occupation | Section Hand R.R. | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 22 | Father's Age |
| Mother's Given Name | Helen Martha J. | Johnson | Mother's Maiden Name |
| Mother's Surname | Ericksen | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jennie, Mrs. Johnson | Sheldahl IA | Medical Attendant's Address |
| Certificate Signer's Name | A.J., Mrs. Bartlett | | Certificate Signer's Address |
| Returned by Name | A.J., Mrs. Bartlett | | |