| Certificate Number | 40 | | Date Issued |
| Child Given Name | Severin Lewis |
Ostrem | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Dec 1884 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Henry |
Ostem | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | Norway | 24 | Father's Age |
| Mother's Given Name | Anna | Kvale | Mother's Maiden Name |
| Mother's Surname | Ostrem | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |