| Certificate Number | 187 | | Date Issued |
| Child Given Name | Martha E. |
Jacobson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 May 1889 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Ole |
Jacobson | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Norway | 39 | Father's Age |
| Mother's Given Name | Betsey | Abrahamson | Mother's Maiden Name |
| Mother's Surname | | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 38 | 8 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |