| Certificate Number | 109 | | Date Issued |
| Child Given Name | John |
Jensen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Feb 1889 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Lars |
Jensen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 39 | Father's Age |
| Mother's Given Name | Mary | Nelson | Mother's Maiden Name |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |