| Certificate Number | 298 | | Date Issued |
| Child Given Name | Rosa |
Elliot | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Apr 1886 |
| Place of Birth |
| Father's Given Name | Levi |
Elliot | Father's Surname |
| Father's Occupation | Broom maker | | Father's Nationality |
| Father's Birth Place | Indiana | 33 | Father's Age |
| Mother's Given Name | Sarah C. | Carter | Mother's Maiden Name |
| Mother's Surname | Elliot | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |