| Certificate Number | 411 | | Date Issued |
| Child Given Name | |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 09 Oct 1886 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | W.?.P. |
Johnson | Father's Surname |
| Father's Occupation | Grocer | | Father's Nationality |
| Father's Birth Place | Denmark | 31 | Father's Age |
| Mother's Given Name | Sopha | Brorson | Mother's Maiden Name |
| Mother's Surname | Johnson | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 30 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |