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--� •EDICAL CERTIFICATE OF �ATH
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Kieffer IZ P1ale 3 February 2Z, 1984
Laurence Jose h
O�4WOftDESCCMT •G:-��C�iesl ��..� ��� ,,,,,, �. v�iEO: BIRTMIro..o��.�c�el COUMTTOf DC�Ttl
�,American sa. � 81 sa � � f•^`v � 1 s. Nov. 20 � 1902 �,, Richland
oisi�icr nu.+e�n n OHOTMER IMSTITUTIDn-si�fct�i�ypLvuil�iu. c�v[ pp�EuPi�riuSiri�iii ciDO�
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��, Richland Memorial Hospital �. Inpatient
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.. e. Illinois s. U. S.,A. ,o.. - Married _ ,�. Rosemary Stein
� Retired Farmer �� Oun Farm ;S�crtrrE50nuo1 No
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� �„ 330 E. Eleventh St. ,�� Mt.Carmel a, Yes �� k'abash ��Illinois
� FAIMEi—NAME
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? r'� Joseph Kieffer Mary Schmitt
15. 16.
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��o_ Rosemary Kieffer Ii�p.Wife „�. 33o E. llth ST. Mt. Carmel, IL 62863
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1�. DEATM WAS CAVSED BY: __ (�.n. o•.. oryE c u.� .o. I.L mL.•o 1c11 •n.u. o.�n..e ou..
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BU¢IAL. C¢EMAiION, CEMEIEQT OR CREMA70 Y—
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z. Burial ��bSt Mary's Cemetery �i Mt CArmel Illinois z�d
FU:vFRAI HOME NAME �*.cn ..o .����• o. .. r. o. n o�
z�. Sho Funeral Home 527 Mulberry ST. Mt. Carmel ,uNtll o«c o�5,,,,,,062863 Nuµef,
FVNERAI DIR R'S SIGN CE
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IIIInOI3 Departmeryt'c�f PuDllc Holtb -Of�ict oi VILI Reco�03 (BASED �N 1978 U.S. STAMpARD CEATIFICA:O
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CERTIFICATIOIv' MAr 21 1999
STA� OF ILLZNOIS ) �!
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COUNTY Oi RICHLAND ) GIBSON Ci�U TY AUDITOR
I, Wayne D. Seely, County Clerk & Recorder, in ar.d for said County in the State
aforeeaid, do hereby certify that the fore�ing is a true and complete copy of the a'oove
record as the same appears froo the records and files nov in thie office res:aining.
Y1� 1984 �
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'n'ayne D. Seel , County Clerk &, c�er
Olr.ey, llin�is 62450