| Certificate Number | 120 | | Date Issued |
| Child Given Name | James |
Ericksen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Feb 1889 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Ammond |
Ericksen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 45 | Father's Age |
| Mother's Given Name | Mary | Egland | Mother's Maiden Name |
| Mother's Surname | | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 34 | 7 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |