| Certificate Number | 513 | | Date Issued |
| Child Given Name | Christina |
Larson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Sep 1882 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Jans |
Larson | Father's Surname |
| Father's Occupation | Blacksmith | Dane | Father's Nationality |
| Father's Birth Place | Denmark | | Father's Age |
| Mother's Given Name | Mrs. | | Mother's Maiden Name |
| Mother's Surname | Larson | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | | 7 | Number of Child This Mother |
| Medical Attendant's Name | Sarah A. Boston | Warren Twp IA | Medical Attendant's Address |
| Certificate Signer's Name | Sarah A. Boston | Warren Twp IA | Certificate Signer's Address |
| Returned by Name | S.A. Boston | | |