| Certificate Number | 53 | | Date Issued |
| Child Given Name | Ingval |
Hendrickson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Dec 1884 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Henry |
Hendrickson | Father's Surname |
| Father's Occupation | Painter | | Father's Nationality |
| Father's Birth Place | Norway | 23 | Father's Age |
| Mother's Given Name | Elsia | Olson | Mother's Maiden Name |
| Mother's Surname | Hendrickson | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 30 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hays | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hays | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hays | | |