| Certificate Number | 811 | | Date Issued |
| Child Given Name | |
Jacobson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Nov 1883 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | A.H. |
Jacobson | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 24 | Father's Age |
| Mother's Given Name | Mrs. A.H. | Jacobsen | Mother's Maiden Name |
| Mother's Surname | Jacobson | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |