| Certificate Number | 566 | | Date Issued |
| Child Given Name | Jennie |
Johnson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 May 1887 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Andrew J. |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 39 | Father's Age |
| Mother's Given Name | Mattie | Holland | Mother's Maiden Name |
| Mother's Surname | Johnson | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 38 | 6 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |