| Certificate Number | 472 | | Date Issued |
| Child Given Name | |
Holm | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Sep 1882 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Hans Christian |
Holmes | Father's Surname |
| Father's Occupation | Preacher | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 27 | Father's Age |
| Mother's Given Name | Carrie O. | Appland | Mother's Maiden Name |
| Mother's Surname | Holmes | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes M.D. | | |