| Certificate Number | 240 | | Date Issued |
| Child Given Name | Martha B. |
Omvig | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Nov 1885 |
South of Elsworth Hamilton Co IA | Place of Birth |
| Father's Given Name | John |
Omvig | Father's Surname |
| Father's Occupation | Laborer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 18 | Father's Age |
| Mother's Given Name | Sophia | Anderson | Mother's Maiden Name |
| Mother's Surname | Omvig | Elsworth | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |