| Certificate Number | 261 | | Date Issued |
| Child Given Name | |
Johnson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Aug 1889 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Gustavus |
Johnson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 25 | Father's Age |
| Mother's Given Name | Gurena | Larsen | Mother's Maiden Name |
| Mother's Surname | | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |