| Certificate Number | 313 | | Date Issued |
| Child Given Name | Harvey Addison |
Lough | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 09 Jan 1882 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Addison E. |
Lough | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | U.S. | 22 | Father's Age |
| Mother's Given Name | Myrah J. | Fry | Mother's Maiden Name |
| Mother's Surname | Lough | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | U.S. | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Boggess M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Boggess M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.W. Boggess M.D. | | |