| Certificate Number | 812 | | Date Issued |
| Child Given Name | |
Oien | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Story City Story Co IA | Place of Birth |
| Father's Given Name | I.A. |
Oien | Father's Surname |
| Father's Occupation | Shoemaker | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 49 | Father's Age |
| Mother's Given Name | Dorathay | Johnson | Mother's Maiden Name |
| Mother's Surname | Oien | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 34 | 9 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |