| Certificate Number | 186 | | Date Issued |
| Child Given Name | Lewis Gilbert |
Tesdahl | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Oct 1885 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | O.S. |
Tesdahl | Father's Surname |
| Father's Occupation | Farming | | Father's Nationality |
| Father's Birth Place | Union Twp Story Co IA | 300 | Father's Age |
| Mother's Given Name | Martha C. | Johnson | Mother's Maiden Name |
| Mother's Surname | Tesdahl | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Union | Mother's Birth Place |
| Mother's Age | 25 | 4 | Number of Child This Mother |
| Medical Attendant's Name | L., Mrs. Frawvie | Huxley IA | Medical Attendant's Address |
| Certificate Signer's Name | L., Mrs. Frawvie | Huxley IA | Certificate Signer's Address |
| Returned by Name | O.L. Tesdahl | | |