| Certificate Number | 71 | | Date Issued |
| Child Given Name | John Arens |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 09 Jan 1890 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Jen |
Johnson | Father's Surname |
| Father's Birth Place | Illinois | 32 | Father's Age |
| Mother's Given Name | Lina | Jensen | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Anna G. Torkhein | Story City IA | Medical Attendant's Address |