| Certificate Number | 139 | | Date Issued |
| Child Given Name | John Theodore |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Jan 1886 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Ole N. |
Johnson | Father's Surname |
| Father's Occupation | R. Roader | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 21 | Father's Age |
| Mother's Given Name | Bertha | Iverson | Mother's Maiden Name |
| Mother's Surname | Johnson | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 30 | 1 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |