| Certificate Number | 758 | | Date Issued |
| Child Given Name | Blanch Mayme |
Johnsen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Feb 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Andy |
Johnsen | Father's Surname |
| Father's Occupation | Engineer | Swede | Father's Nationality |
| Father's Birth Place | Sweden | | Father's Age |
| Mother's Given Name | Mary Mahala | Pitsenbarger | Mother's Maiden Name |
| Mother's Surname | Johnsen | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | Swede | Sweden | Mother's Birth Place |
| Mother's Age | | 4 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |