| Certificate Number | 22 | | Date Issued |
| Child Given Name | |
John | Child Surname |
| Child Sex | Male |
A | Child Race |
| Date of Birth | 22 Aug 1880 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | D.W. |
Johnson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 28 | Father's Age |
| Mother's Given Name | B.E. | Olinger | Mother's Maiden Name |
| Mother's Surname | Johns | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo. P. Johnston | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. P. Johnston | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Geo. P. Johnston | | |