| Certificate Number | 852 | | Date Issued |
| Child Given Name | |
Hard | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Oct 1883 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | William M. |
Hard | Father's Surname |
| Father's Occupation | Engineer | | Father's Nationality |
| Father's Birth Place | | 32 | Father's Age |
| Mother's Given Name | Mary Loving | Harper | Mother's Maiden Name |
| Mother's Surname | Hardesty | Maxwell Story Co IA | Mother's Residence |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell IA | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Maxwell IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |