| Certificate Number | 614 | | Date Issued |
| Child Given Name | |
Mathiason | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Jun 1887 |
| Place of Birth |
| Father's Given Name | Lars |
Mathiason | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 49 | Father's Age |
| Mother's Given Name | Sinna | | Mother's Maiden Name |
| Mother's Surname | Mathiason | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 39 | 8 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |