| Certificate Number | 184 | | Date Issued |
| Child Given Name | Helen |
Eydal | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Apr 1889 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Nels |
Eydal | Father's Surname |
| Father's Birth Place | Norway | 39 | Father's Age |
| Mother's Given Name | Elen M. | Axelton | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 37 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Martina, Mrs. Berkland | Roland IA | Medical Attendant's Address |