| Certificate Number | 910 | | Date Issued |
| Child Given Name | |
Dale | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Mar 1884 |
Howard Twp Story Co IA | Place of Birth |
| Father's Given Name | J.B.A. |
Dale | Father's Surname |
| Father's Occupation | Stone Mason | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 29 | Father's Age |
| Mother's Given Name | Julia A. | Oleson | Mother's Maiden Name |
| Mother's Surname | Dale | | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 18 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |