| Certificate Number | 95 | | Date Issued |
| Child Given Name | John |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Jan 1890 |
Warren 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 | Norway | 34 | Father's Age |
| Mother's Given Name | Gusti | Thompson | Mother's Maiden Name |
| Mother's Surname | | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 32 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |