| Certificate Number | 30 | | Date Issued |
| Child Given Name | Inger |
Grotness | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Oct 1887 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Samson |
Grotness | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Norway | 30 | Father's Age |
| Mother's Given Name | Inger J. | Myren | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 28 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Annie Tokheim | Story City IA | Medical Attendant's Address |