| Certificate Number | 911 | | Date Issued |
| Child Given Name | |
Sheldahl | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Mar 1884 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | A.H. |
Sheldahl | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 28 | Father's Age |
| Mother's Given Name | Bell C. | Tesdahl | Mother's Maiden Name |
| Mother's Surname | Sheldahl | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Phoebe Hopkins | Huxley IA | Medical Attendant's Address |
| Certificate Signer's Name | Phoebe Hopkins | Huxley IA | Certificate Signer's Address |
| Returned by Name | 'Mail' | | |