| Certificate Number | 103 | | Date Issued |
| Child Given Name | |
Elliott | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | James F. |
Elliott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Greensbeorgh IN | 29 | Father's Age |
| Mother's Given Name | Ida J. | Chandler | Mother's Maiden Name |
| Mother's Surname | Elliott | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Newfoxcraft ME | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |