| Certificate Number | 486 | | Date Issued |
| Child Given Name | Harry Le Roy |
Miller | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Oct 1882 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Harvey E. |
Miller | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Virginia | 37 | Father's Age |
| Mother's Given Name | Eliza J. | Hedges | Mother's Maiden Name |
| Mother's Surname | Miller | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 35 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |