| Certificate Number | 204 | | Date Issued |
| Child Given Name | Gracie |
Borgen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Sep 1885 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Martin |
Borgen | Father's Surname |
| Father's Occupation | Furniture | | Father's Nationality |
| Father's Birth Place | Norway | 41 | Father's Age |
| Mother's Given Name | Julia | Olson | Mother's Maiden Name |
| Mother's Surname | Borgen | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 31 | 7 | 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.H. Munk | | |