| Certificate Number | 21 | | Date Issued |
| Child Given Name | |
Tesdahl | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 Oct 1887 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Oliver |
Tesdahl | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 32 | 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 | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 5 | Number of Child This Mother |
| Medical Attendant's Name | P.C. Heggem | Huxley IA | Medical Attendant's Address |