| Certificate Number | 256 | | Date Issued |
| Child Given Name | |
Veign | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Jan 1886 |
Gilbert Station Story Co IA | Place of Birth |
| Father's Given Name | George |
Veign | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 22 | Father's Age |
| Mother's Given Name | Maggie | Solbertson | Mother's Maiden Name |
| Mother's Surname | Veign | Gilbert Station Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.F. Fairchild | Ames IA | Medical Attendant's Address |