| Certificate Number | 366 | | Date Issued |
| Child Given Name | Lars |
Larsen | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 16 Mar 1882 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Halle |
Larsen | Father's Surname |
| Father's Occupation | Farming | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | | Father's Age |
| Mother's Given Name | Julia | | Mother's Maiden Name |
| Mother's Surname | Larsen | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | | 5 | Number of Child This Mother |
| Medical Attendant's Name | H.C. Holen | | Medical Attendant's Address |
| Certificate Signer's Name | H.C. Holen | | Certificate Signer's Address |
| Returned by Name | H.C. Holen | | |