| Certificate Number | 554 | | Date Issued |
| Child Given Name | Katie Nora |
Christopher | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Ole |
Christopher | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 23 | Father's Age |
| Mother's Given Name | Ellen | Tesdahl | Mother's Maiden Name |
| Mother's Surname | Christopher | Grant Twp 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 | A.S. Aplin | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | A.S. Aplin | Cambridge IA | Certificate Signer's Address |
| Returned by Name | A.S Aplin | | |