| Certificate Number | 773 | | Date Issued |
| Child Given Name | |
Johnsen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Jun 1882 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Lyman |
Johnsen | Father's Surname |
| Father's Occupation | Grain Merchant | American | Father's Nationality |
| Father's Birth Place | New York | 32 | Father's Age |
| Mother's Given Name | Cenna | Nobel | Mother's Maiden Name |
| Mother's Surname | Johnsen | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Maryland | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |