| Certificate Number | 628 | | Date Issued |
| Child Given Name | Mary Alice |
Larson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Apr 1883 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Hans T. |
Larson | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 51 | Father's Age |
| Mother's Given Name | Koisa | Orbinson | Mother's Maiden Name |
| Mother's Surname | Larson | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |