| Child Given Name | Harry Le Roy |
Severson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Aug 1894 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Samuel Smith |
Severson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 35 | Father's Age |
| Mother's Given Name | Mary Elizabeth | Wills | Mother's Maiden Name |
| Mother's Surname | Severson | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 28 | 6 | Number of Child This Mother |
| Certificate Signer's Name | Samuel S. Severson | | Certificate Signer's Address |