| Certificate Number | 343 | | Date Issued |
| Child Given Name | |
Harrison | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Jun 1886 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | William F. |
Harrison | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 19 | Father's Age |
| Mother's Given Name | Dora L. | Palmatier | Mother's Maiden Name |
| Mother's Surname | Palmatier | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 17 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |