| Certificate Number | 350 | | Date Issued |
| Child Given Name | Jas. L. |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Sep 1889 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | James |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | England | 37 | Father's Age |
| Mother's Given Name | Mary E. | Briley | Mother's Maiden Name |
| Mother's Surname | | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 32 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |