| Certificate Number | 99 | | Date Issued |
| Child Given Name | |
Johnson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Feb 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Johnson | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Norway | 21 | Father's Age |
| Mother's Given Name | Sarah | Thompson | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |