| Certificate Number | 465 | | Date Issued |
| Child Given Name | Guy Walter |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 06 Dec 1886 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | August |
Johnson | Father's Surname |
| Father's Occupation | Farmer | Swede | Father's Nationality |
| Father's Birth Place | Sweden | 26 | Father's Age |
| Mother's Given Name | Mary J. | | Mother's Maiden Name |
| Mother's Surname | Johnson | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Swede | Sweden | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D. Tisdahl | Zearing IA | Medical Attendant's Address |