| Certificate Number | 114 | | Date Issued |
| Child Given Name | |
Elliott | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Apr 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | George A. |
Elliott | Father's Surname |
| Father's Occupation | Engineer | American | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | A. | Augasta | Mother's Maiden Name |
| Mother's Surname | Elliott | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 21 | 3 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |