| Certificate Number | 123 | | Date Issued |
| Child Given Name | |
Harris | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Apr 1890 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas W. |
Harris | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa Co IA | 27 | Father's Age |
| Mother's Given Name | Louise L. | Lightfoot | Mother's Maiden Name |
| Mother's Surname | | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Kane Co IL | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |