| Certificate Number | 991 | | Date Issued |
| Child Given Name | Martha E. |
Jacobsen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Jun 1884 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Ole |
Jakobson | Father's Surname |
| Father's Occupation | Blacksmith | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 34 | Father's Age |
| Mother's Given Name | Bertha | Jacobson | Mother's Maiden Name |
| Mother's Surname | Jackobson | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 33 | 6 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hays | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hays | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hays | | |