| Certificate Number | 309 | | Date Issued |
| Child Given Name | |
Hansen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Oct 1881 |
Sheldahl Story Co IA | Place of Birth |
| Father's Given Name | H.N. |
Hansen | Father's Surname |
| Father's Occupation | Blacksmith | Dane | Father's Nationality |
| Father's Birth Place | Denmark | 27 | Father's Age |
| Mother's Given Name | Bertie | Ferevig | Mother's Maiden Name |
| Mother's Surname | Hansen | Sheldahl Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Jes. A. Anderson | Sheldahl IA | Medical Attendant's Address |
| Certificate Signer's Name | Jes. A. Anderson | Sheldahl IA | Certificate Signer's Address |
| Returned by Name | Jes. A. Anderson | | |