| Certificate Number | 42 | | Date Issued |
| Child Given Name | Herbert J. |
Jensen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Nov 1888 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Peder |
Jensen | Father's Surname |
| Father's Occupation | Druggist | | Father's Nationality |
| Father's Birth Place | Denmark | 24 | Father's Age |
| Mother's Given Name | Agnes | Anderson | 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 | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | John Emmett | Story City IA | Medical Attendant's Address |