| Certificate Number | 121 | | Date Issued |
| Child Given Name | Harrison |
| Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Mar 1889 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | H.S. |
Converse | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Michigan | 37 | Father's Age |
| Mother's Given Name | Della | Cleveland | Mother's Maiden Name |
| Mother's Surname | | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 37 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |