| Child Given Name | Rose |
Fosse | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 22 Sep 1884 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Ole O. |
Fosse | Father's Surname |
| Father's Occupation | | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 30 | Father's Age |
| Mother's Given Name | Serelena | Helgen | Mother's Maiden Name |
| Mother's Surname | | Norway | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 23 | | Number of Child This Mother |
| Medical Attendant's Name | Ole O., Dr. Fosse | | Medical Attendant's Address |