| Certificate Number | 817 | | Date Issued |
| Child Given Name | Walter |
Paulson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 06 Dec 1883 |
| Place of Birth |
| Father's Given Name | John |
Paulson | Father's Surname |
| Father's Occupation | Farmer | Dane | Father's Nationality |
| Father's Birth Place | Denmark | 34 | Father's Age |
| Mother's Given Name | Maria | | Mother's Maiden Name |
| Mother's Surname | Paulson | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | 57 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.A. Munk | | |