| Certificate Number | 15 | | Date Issued |
| Child Given Name | |
Fatlana | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 38 Oct 1884 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Brit |
Fatlana | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Illinois | 32 | Father's Age |
| Mother's Given Name | Elsie | Berhow | Mother's Maiden Name |
| Mother's Surname | Fatlana | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 27 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown M.D. | | |