| Certificate Number | 57 | | Date Issued |
| Child Given Name | |
Johnson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Dec 1889 |
Howard Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo. |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 32 | Father's Age |
| Mother's Given Name | Annie | Johnson | Mother's Maiden Name |
| Mother's Surname | | Howard Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 25 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Peterson | Story City IA | Medical Attendant's Address |