| Certificate Number | 16 | | Date Issued |
| Child Given Name | Lillie Elise |
Frandson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Sep 1889 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Christian |
Frandson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 34 | Father's Age |
| Mother's Given Name | Anna | Hermanson | Mother's Maiden Name |
| Mother's Surname | | LaFayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 32 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Peterson | Story City IA | Medical Attendant's Address |