| Certificate Number | 162 | | Date Issued |
| Child Given Name | |
Hart | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Apr 1889 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Wm H. |
Hart | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Ohio | 21 | Father's Age |
| Mother's Given Name | | Miller | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |