| Certificate Number | 12 | | Date Issued |
| Child Given Name | Mates |
Mateson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Jul 1880 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Bartel |
Mateson | Father's Surname |
| Father's Occupation | Laborer | Dane | Father's Nationality |
| Father's Birth Place | Denmark | 25 | Father's Age |
| Mother's Given Name | Christena | Johnson | Mother's Maiden Name |
| Mother's Surname | Mateson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Bogges | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Bogges | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.W. Bogges | | |