| Certificate Number | 38 | | Date Issued |
| Child Given Name | |
Iversen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Oct 1889 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Lars |
Iverson | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Norway | 30 | Father's Age |
| Mother's Given Name | Rachel | Andrews | 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 | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Peterson | Story City IA | Medical Attendant's Address |