| Certificate Number | 159 | | Date Issued |
| Child Given Name | |
Jacobsen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Jun 1890 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Ludvig |
Jacobsen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 27 | Father's Age |
| Mother's Given Name | Katie | Nelson | Mother's Maiden Name |
| Mother's Surname | | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |