| Certificate Number | 12 | | Date Issued |
| Child Given Name | Alfred William |
Rustad | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Oct 1891 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Emil |
Rustact | Father's Surname |
| Father's Occupation | Book Keeper | | Father's Nationality |
| Father's Birth Place | Denmark | 29 | Father's Age |
| Mother's Given Name | Jennie | Hanson | Mother's Maiden Name |
| Mother's Surname | Rustact | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Chicago IL | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |