| Certificate Number | 576 | | Date Issued |
| Child Given Name | |
Hegland | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Jan 1883 |
Howard Twp Story Co IA | Place of Birth |
| Father's Given Name | Ole |
Hegland | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 41 | Father's Age |
| Mother's Given Name | Carrie Anna | Iverson | Mother's Maiden Name |
| Mother's Surname | Hegland | Howard Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 33 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |