| Certificate Number | 44 | | Date Issued |
| Child Given Name | Ales |
Jacobsen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Nov 1889 |
McCallsburg Story Co IA | Place of Birth |
| Father's Given Name | Hans |
Jacobsen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 29 | Father's Age |
| Mother's Given Name | Anne Helene | Hansken | Mother's Maiden Name |
| Mother's Surname | | McCallsburg Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Grethe Skogerboe | Roland IA | Medical Attendant's Address |