| Certificate Number | 321 | | Date Issued |
| Child Given Name | Violet Marie |
Hartsel | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 06 Jun 1886 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | G.W. |
Hartsel | Father's Surname |
| Father's Occupation | Drayman | | Father's Nationality |
| Father's Birth Place | Indiana | 34 | Father's Age |
| Mother's Given Name | Lillian | Lawson | Mother's Maiden Name |
| Mother's Surname | Hartsel | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 32 | | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |