| Certificate Number | 104 | | Date Issued |
| Child Given Name | |
Harrison | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 23 Jan 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Samuel A. |
Harrison | Father's Surname |
| Father's Occupation | Clerk in a store | American | Father's Nationality |
| Father's Birth Place | Harrison Co OH | 44 | Father's Age |
| Mother's Given Name | Elizabeth A. | Wilcox | Mother's Maiden Name |
| Mother's Surname | Harrison | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Erie PA | Mother's Birth Place |
| Mother's Age | 40 | 8 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |