| Certificate Number | 236 | | Date Issued |
| Child Given Name | |
Harman | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 12 Sep 1881 |
Sherman Twp Story Co iA | Place of Birth |
| Father's Given Name | Walfred |
Hartman | Father's Surname |
| Father's Occupation | Farmer | Prussian | Father's Nationality |
| Father's Birth Place | Prussia | 36 | Father's Age |
| Mother's Given Name | Lina | Binker | Mother's Maiden Name |
| Mother's Surname | Hartman | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Prussian | Prussia | Mother's Birth Place |
| Mother's Age | 30 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |