81443-180368-0681

State File Number: 358

County: Salt Lake

Child's First Name: Wallace

Child's Middle Name 1: H

Child's Middle Name 2:

Child's Middle Name 3:

Child's Surname: Johnson

Child's Suffix:

Sex: Male

Month of Birth (Number): 02

Day of Birth: 04

Year of Birth: 1912

Father's First Name: Carl

Father's Middle Name 1: G

Father's Middle Name 2:

Father's Surname: Johnson

Father's Title or Suffix:

Mother's First Name: Elanore

Mother's Middle Name 1:

Mother's Middle Name 2:

Mother's Maiden Name: Lundgren

Is there an Amendment?: No