| Certificate Number | 570 | | Date Issued |
| Child Given Name | Jens P. |
Larsen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Jun 1887 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Christian |
Larsen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 49 | Father's Age |
| Mother's Given Name | Christine | Olsen | Mother's Maiden Name |
| Mother's Surname | Larsen | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 31 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Maria, Mrs. Anderson | Nevada IA | Medical Attendant's Address |