| Certificate Number | 329 | | Date Issued |
| Child Given Name | |
Johnson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Dec 1881 |
| Place of Birth |
| Father's Given Name | Henry |
Johnson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 40 | Father's Age |
| Mother's Surname | | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 35 | 7 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merredith M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merredith M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merredith M.D. | | |