| Certificate Number | 517 | | Date Issued |
| Child Given Name | |
Hartsel | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Feb 1887 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | John |
Hartsel | Father's Surname |
| Father's Occupation | Drayman | | Father's Nationality |
| Father's Birth Place | Indiana | 31 | Father's Age |
| Mother's Given Name | Minnie | Nelson | Mother's Maiden Name |
| Mother's Surname | Hartsel | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Chicago | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |