| Certificate Number | 359 | | Date Issued |
| Child Given Name | Clara B. |
Johnson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Aug 18898 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | John K. |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 29 | Father's Age |
| Mother's Given Name | Bertha J. | Gaard | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Brethe Skogerboe | Roland IA | Medical Attendant's Address |