| Certificate Number | 601 | | Date Issued |
| Child Given Name | Lillie D. |
Jensen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Jul 1887 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Lars |
Jensen | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Denmark | 28 | Father's Age |
| Mother's Given Name | Laura | Hansen | Mother's Maiden Name |
| Mother's Surname | Jensen | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Mary, Mrs. Johnson | Nevada IA | Medical Attendant's Address |