| Certificate Number | 50 | | Date Issued |
| Child Given Name | |
Elliott | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Dec 1889 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Hiram |
Elliott | Father's Surname |
| Father's Occupation | Engineer | | Father's Nationality |
| Father's Birth Place | Henry Co IN | 51 | Father's Age |
| Mother's Given Name | Alice | Johnson | Mother's Maiden Name |
| Mother's Surname | | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |