| Certificate Number | 613 | | Date Issued |
| Child Given Name | Nellie |
Johnson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 Aug 1887 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | C.E. |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 19 | Father's Age |
| Mother's Given Name | Nettie | Howard | Mother's Maiden Name |
| Mother's Surname | Johnson | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 17 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |