| Certificate Number | 931 | | Date Issued |
| Child Given Name | |
Haaland | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Apr 1884 |
| Place of Birth |
| Father's Given Name | George |
Haaland | Father's Surname |
| Father's Occupation | Laborer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 26 | Father's Age |
| Mother's Given Name | Martha | Furgeson | Mother's Maiden Name |
| Mother's Surname | Haaland | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |