| Certificate Number | 285 | | Date Issued |
| Child Given Name | |
Holen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Jan 1886 |
| Place of Birth |
| Father's Given Name | John J. |
Holen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 39 | Father's Age |
| Mother's Given Name | Bertha | Jacobsen | Mother's Maiden Name |
| Mother's Surname | Holen | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |