| Certificate Number | 217 | | Date Issued |
| Child Given Name | |
Jacobs | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Aug 1888 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Nels B. |
Jacobs | Father's Surname |
| Father's Occupation | Butcher | | Father's Nationality |
| Father's Birth Place | Norway | 36 | Father's Age |
| Mother's Given Name | Maria B. | Olson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 36 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |