| Certificate Number | 241 | | Date Issued |
| Child Given Name | |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Mar 1888 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | L.M. |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 45 | Father's Age |
| Mother's Given Name | Lena | Miller | Mother's Maiden Name |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 29 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Geo. P. Stitzell | Nevada IA | Medical Attendant's Address |