| Certificate Number | 993 | | Date Issued |
| Child Given Name | Anna |
Hand | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 May 1884 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | John |
Hana | Father's Surname |
| Father's Occupation | Laborer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 28 | Father's Age |
| Mother's Given Name | Thea O. | Rasmusen | Mother's Maiden Name |
| Mother's Surname | Hanna | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 24 | 3 | 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 | | |