| Certificate Number | 126 | | Date Issued |
| Child Given Name | Benford W. |
Evenson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Apr 1890 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | John |
Evenson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 55 | Father's Age |
| Mother's Given Name | Marie | Lura | 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 | 28 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Gretha M. Skogerbor | Roland IA | Medical Attendant's Address |