| Certificate Number | 244 | | Date Issued |
| Child Given Name | |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Sep 1888 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Clinton E. |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Grant Co IN | 20 | Father's Age |
| Mother's Given Name | Jennette | Howard | Mother's Maiden Name |
| Mother's Surname | | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Grant Co IN | Mother's Birth Place |
| Mother's Age | 18 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |