| Certificate Number | 155 | | Date Issued |
| Child Given Name | John Leland |
Lewis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Jul 1885 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Ole |
Leland | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 27 | Father's Age |
| Mother's Given Name | Bertha | Red | Mother's Maiden Name |
| Mother's Surname | | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 16 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Anna, Mrs. Red | | Medical Attendant's Address |
| Certificate Signer's Name | A.S. Aplin | Cambridge IA | Certificate Signer's Address |
| Returned by Name | A.S. Aplin | | |