| Certificate Number | 163 | | Date Issued |
| Child Given Name | |
Olsen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Mar 1889 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Andrew T. |
Olsen | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Norway | 32 | Father's Age |
| Mother's Given Name | Inger | Rod | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 29 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Martine Birkland | Roland IA | Medical Attendant's Address |