| Certificate Number | 248 | | Date Issued |
| Child Given Name | |
Ellis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Jun 1889 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | G.H. |
Ellis | Father's Surname |
| Father's Occupation | Dentist | | Father's Nationality |
| Father's Birth Place | Massachusets | 43 | Father's Age |
| Mother's Given Name | Mertie | Shields | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell Ia | Medical Attendant's Address |