| Child Given Name | John |
Irvine | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Jan 1885 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Johnston |
Irvine | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ireland | 27 | Father's Age |
| Mother's Given Name | Tina | Menzel | Mother's Maiden Name |
| Mother's Surname | Irvine | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Germany | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Fanny McClain | McCallsburg IA | Medical Attendant's Address |
| Certificate Signer's Name | Fanny McClain | McCallsburg IA | Certificate Signer's Address |
| Returned by Name | P. McClain | | |