| Certificate Number | 32 | | Date Issued |
| Child Given Name | Sirina |
Harrison | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 30 Dec 1994 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Charles |
Harrison | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 26 | Father's Age |
| Mother's Given Name | Harriet | Spencer | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.H., Dr. Rosenburg | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.H., Dr. Rosenburg | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.H., Dr. Rosenburg | | |