| Certificate Number | 247 | | Date Issued |
| Child Given Name | |
Erickson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 Apr 1890 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Charlie |
Erickson | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Norway | 36 | Father's Age |
| Mother's Given Name | Annie | Sampson | Mother's Maiden Name |
| Mother's Surname | | Story City 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 | Sina Pederson | Story City IA | Medical Attendant's Address |
| Returned by Name | John Molstru | | |