| Certificate Number | 240 | | Date Issued |
| Child Given Name | Clara Theresa |
Johnson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Apr 1888 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | August |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Sweden | 27 | Father's Age |
| Mother's Given Name | Mary J. | Johnson | Mother's Maiden Name |
| Mother's Surname | | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Sweden | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |