| Certificate Number | 235 | | Date Issued |
| Child Given Name | Otis |
Goard | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Jun 1889 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Andreas |
Goard | Father's Surname |
| Father's Occupation | Painter | | Father's Nationality |
| Father's Birth Place | Norway | 28 | Father's Age |
| Mother's Given Name | Gurine | Kjerandson | 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 | 37 | 5 | Number of Child This Mother |
| Medical Attendant's Name | John Emmet | Story City IA | Medical Attendant's Address |