| Certificate Number | 226 | | Date Issued |
| Child Given Name | Levi L. |
Elliott | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 07 Sep 1881 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Levi L. |
Elliott | Father's Surname |
| Father's Occupation | Broom maker | American | Father's Nationality |
| Father's Birth Place | Indiana | 29 | Father's Age |
| Mother's Given Name | Sarah C. | Carter | Mother's Maiden Name |
| Mother's Surname | Elliott | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | S.J. Starr | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | S.J. Starr | Ames IA | Certificate Signer's Address |
| Returned by Name | S.J. Starr | | |