| Certificate Number | 553 | | Date Issued |
| Child Given Name | |
Lewis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Erasmus |
Lewis | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 52 | Father's Age |
| Mother's Given Name | Anna M. | Johnson | Mother's Maiden Name |
| Mother's Surname | Lewis | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 43 | 11 | Number of Child This Mother |
| Medical Attendant's Name | A.S. Aplin | Cambridge IA | Medical Attendant's Address |