| Certificate Number | 179 | | Date Issued |
| Child Given Name | |
Erickson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 May 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Sam |
Erickson | Father's Surname |
| Father's Occupation | R.R. Hand | | Father's Nationality |
| Father's Birth Place | Norway | 25 | Father's Age |
| Mother's Given Name | Helen | Johnson | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |