| Certificate Number | 654 | | Date Issued |
| Child Given Name | |
Johnson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Jun 1883 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Oliver M. |
Johnson | Father's Surname |
| Father's Occupation | Merchant | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 33 | Father's Age |
| Mother's Given Name | Alice | Larson | Mother's Maiden Name |
| Mother's Surname | Johnson | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 29 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |