| Certificate Number | 66 | | Date Issued |
| Child Given Name | Ray |
Hardesty | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | David W. |
Hardesty | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Ohio | 26 | Father's Age |
| Mother's Given Name | Nellie | Bronson | Mother's Maiden Name |
| Mother's Surname | Hardesty | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Ogle Co IL | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.E. Scott | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.E. Scott | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.E. Scott | | |