| Certificate Number | 94 | | Date Issued |
| Child Given Name | |
Oleson | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | |
Howard Twp Story Co IA | Place of Birth |
| Father's Given Name | Hans |
Oleson | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 27 | Father's Age |
| Mother's Given Name | Sarah | Gunderson | Mother's Maiden Name |
| Mother's Surname | Oleson | Howard Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |