| Certificate Number | 190 | | Date Issued |
| Child Given Name | |
Oberson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Sep 1885 |
Boone Co IA | Place of Birth |
| Father's Given Name | Levie |
Oberson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 24 | Father's Age |
| Mother's Given Name | Cristena | Oberson | Mother's Maiden Name |
| Mother's Surname | Oberson | Boone Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |