| Certificate Number | 103 | | Date Issued |
| Child Given Name | Harry M. |
Rice | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Jan 1889 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | E.C. |
Rice | Father's Surname |
| Father's Occupation | Well Driller | | Father's Nationality |
| Father's Birth Place | Lasalle Co IL | 31 | Father's Age |
| Mother's Given Name | Hattie M. | Maxwell | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 28 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |