| Certificate Number | 445 | | Date Issued |
| Child Given Name | |
Thorsen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Thomas |
Thorsen | Father's Surname |
| Father's Occupation | Laborer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 25 | Father's Age |
| Mother's Given Name | | Oleson | Mother's Maiden Name |
| Mother's Surname | Thorsen | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 22 | 4 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar M.D. | | |