| Certificate Number | 412 | | Date Issued |
| Child Given Name | |
Carlson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Oct 1886 |
| Place of Birth |
| Father's Given Name | Hans |
Carlson | Father's Surname |
| Father's Occupation | Printer | | Father's Nationality |
| Father's Birth Place | Denmark | 23 | Father's Age |
| Mother's Given Name | S.A. | Wallace | Mother's Maiden Name |
| Mother's Surname | Carlson | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B.F Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |