| Certificate Number | 336 | | Date Issued |
| Child Given Name | |
Mathenson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Apr 1886 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Barlte |
Mathenson | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Denmark | 34 | Father's Age |
| Mother's Given Name | Matilda | | Mother's Maiden Name |
| Mother's Surname | Mathenson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | | 1 | 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 | | |