| Certificate Number | 272 | | Date Issued |
| Child Given Name | |
Elliot | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 15 Nov 1881 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Freeman |
Elliot | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Kane Co IL | 44 | Father's Age |
| Mother's Given Name | Alma | Lake | Mother's Maiden Name |
| Mother's Surname | Elliot | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Kane Co IL | Mother's Birth Place |
| Mother's Age | 42 | 6 | Number of Child This Mother |
| Certificate Signer's Name | Freeman Elliot | | Certificate Signer's Address |
| Returned by Name | Freeman Elliot | | |