| Certificate Number | 118 | | Date Issued |
| Child Given Name | |
Borgen | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 11 Feb 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Martin L. |
Borgen | Father's Surname |
| Father's Occupation | Furniture Dealer & untaker | | Father's Nationality |
| Father's Birth Place | Norway | | Father's Age |
| Mother's Given Name | Oleson | | Mother's Maiden Name |
| Mother's Surname | Borgen | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | | 5 | Number of Child This Mother |
| Medical Attendant's Name | Henri Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Henri Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | Henri Munk | | |