| Certificate Number | 342 | | Date Issued |
| Child Given Name | Lewellyn G. |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Apr 1889 |
Slater Story Co IA | Place of Birth |
| Father's Given Name | Lars |
Johnson | Father's Surname |
| Father's Occupation | Mechanic | | Father's Nationality |
| Father's Birth Place | Norway | 44 | Father's Age |
| Mother's Given Name | Louisa | Steenson | Mother's Maiden Name |
| Mother's Surname | | Slater Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.A. Rawson | Slater IA | Medical Attendant's Address |