| Certificate Number | 214 | | Date Issued |
| Child Given Name | Lulu Bell |
Hendrickson | Child Surname |
| Child Sex | f |
| Child Race |
| Date of Birth | 14 Aug 1881 |
Palestine Twp Story Co iA | Place of Birth |
| Father's Given Name | H.O. |
Hendrickson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 37 | Father's Age |
| Mother's Given Name | Sarah I. | Hanze | Mother's Maiden Name |
| Mother's Surname | Hendrickson | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Skonevig | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Certificate Signer's Name | H.O. Hendrickson | Sheldahl IA | Certificate Signer's Address |
| Returned by Name | H.O. Hendrickson | | |