| Certificate Number | 626 | | Date Issued |
| Child Given Name | |
Harrell | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Apr 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Jerome |
Harrell | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Indiana | 31 | Father's Age |
| Mother's Given Name | Phoebe Ann | Emery | Mother's Maiden Name |
| Mother's Surname | Harrell | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 24 | 2 | 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 | | |