| Certificate Number | 906 | | Date Issued |
| Child Given Name | |
Harsted | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Mar 1884 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | John |
Harsted | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 28 | Father's Age |
| Mother's Given Name | Minnie A. | Nelson | Mother's Maiden Name |
| Mother's Surname | Harsted | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 19 | 1 | 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 | | |