| Certificate Number | 355 | | Date Issued |
| Child Given Name | Harrison |
Price | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Jul 1889 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Wm. S. |
Price | Father's Surname |
| Father's Occupation | Harness Maker | | Father's Nationality |
| Father's Birth Place | Indiana | 34 | Father's Age |
| Mother's Given Name | Lizzie E. | Nickelson | Mother's Maiden Name |
| Mother's Surname | | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 34 | 6 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |