| Certificate Number | 396 | | Date Issued |
| Child Given Name | Brouhard Selanus |
Erickson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Jun 1886 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | M.S. |
Erikson | Father's Surname |
| Father's Occupation | Sec R.R. | | Father's Nationality |
| Father's Birth Place | Iowa | 27 | Father's Age |
| Mother's Given Name | Helen M. | Benson | Mother's Maiden Name |
| Mother's Surname | Erikson | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Jennie, Mrs. Johnson | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | | Certificate Signer's Address |