| Certificate Number | 491 | | Date Issued |
| Child Given Name | Oley Jr. |
Olson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Nov 1882 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Lars R. |
Olson | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 28 | Father's Age |
| Mother's Given Name | Olena | Johnson | Mother's Maiden Name |
| Mother's Surname | Olson | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Iowa | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes M.D. | | |