| Certificate Number | 67 | | Date Issued |
| Child Given Name | Walter Martin |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Jan 1890 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Peter D. |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 47 | Father's Age |
| Mother's Given Name | Julia | Lewis | Mother's Maiden Name |
| Mother's Surname | | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 38 | 8 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |