| Certificate Number | 816 | | Date Issued |
| Child Given Name | Frank W. |
Johnston | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Nov 1883 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Johnston | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 33 | Father's Age |
| Mother's Given Name | Jane | Irvine | Mother's Maiden Name |
| Mother's Surname | Johnston | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Irish | Ireland | Mother's Birth Place |
| Mother's Age | 30 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Evans | St. Anthony IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Brooks | | |