| Certificate Number | 43 | | Date Issued |
| Child Given Name | Peder H. |
Dale | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 Oct 1888 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | H.L. |
Dale | Father's Surname |
| Father's Occupation | Druggist | | Father's Nationality |
| Father's Birth Place | Norway | 44 | Father's Age |
| Mother's Given Name | Engel | Anderson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 42 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Betsey Mason | Story City IA | Medical Attendant's Address |