| Certificate Number | 148 | | Date Issued |
| Child Given Name | Amelia |
Mathison | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 23 Mar 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Lars |
Mathison | Father's Surname |
| Father's Occupation | Laborer | Dane | Father's Nationality |
| Father's Birth Place | Denmark | | Father's Age |
| Mother's Given Name | Jane | Peterson | Mother's Maiden Name |
| Mother's Surname | Mathison | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |