| Certificate Number | 76 | | Date Issued |
| Child Given Name | Harrison |
Wire | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Jan 1889 |
Kelley Story Co IA | Place of Birth |
| Father's Given Name | Albert |
Wire | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wisconson | 30 | Father's Age |
| Mother's Given Name | Alma A. | Foster | Mother's Maiden Name |
| Mother's Surname | | Kelley Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B.D. Miller | Kelley IA | Medical Attendant's Address |