| Certificate Number | 202 | | Date Issued |
| Child Given Name | Caroline C. |
Larson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Jul 1888 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Rasmus |
Larson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 32 | Father's Age |
| Mother's Given Name | Anna M. | Rasmusson | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Mary, Mrs. Johnson | Nevada IA | Medical Attendant's Address |