| Certificate Number | 358 | | Date Issued |
| Child Given Name | Martin |
Teig | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Sep 1889 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Ole K. |
Tieg | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 40 | Father's Age |
| Mother's Given Name | Ragnihld J. | Rymen | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 34 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Brethe Skogerboe | Roland IA | Medical Attendant's Address |