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~ Tb~s be- iTAT[ .owwo op Nrw~~,+ CER'YIFICATE OF DEATH ~,30¢~ ~,.-,t~~~:F~
co~es • ~vRt/1U OF YITAL ffAT1~TIC, ~TATr FIL[ NO. ~f
l•a•l ~eC- FLOHIDA
ord rhen T N~. R[GISTRAR•i NC. 22
proparlr
e: ~ c u t ~ d 1. ~LAC< OR ~[ATtI GODE NO. 2. YlYAi IR1IKI~Et ( 4M. /w~~t ti«t. Il iwN:ai6w.: Rwidww Man'~"'"~
.pa .1ii ow~hrrSt. LuCie 66~-YX~ sr~~ Florid8 D. COUMTY e~i. LuCiB 7
be placad • J
iq p~p- d. CITY. TOWN, OR LOCATIOM IS ?LACE OF DEATX C. CITY. YOMRI.OIt LACATqN IS RESiDE
•sneat tNS~DE CRY LIMtTSt INSIDE CITY LIMfTSi
r~i.. F P r~s0 MoQ Ft. Pier'ce 8 Rural resp ro(3
I. lMME OF (IJnOI iw AWplhl. IUt Krfl1 a/btM) LENG7N OF I. STREE'I' ADptE55 ON A FAlIM1
, i~iTUia+i st~r iN te St . J a~C'8 RO&d res p~a G~
St James Road 0 3~-Z?
3. Mn1n[ e~ 1rbK NiM[s Lut 1. ~AYE MewtA Dq Yev
~~a+*~> FrCd Walter Knierin ~TH 3une 21; 1 62
5. SEX 6. COIOA OR RACE 7. MARRtEO ~ NEVER MARRlED ~ SIRTM 9. AGE (In /ev! i~~ ~ r~ tMOF~t N wtS•
!sd OirtA/~?) d/.aw P~w Hwr. Niw.
r r 1 e. 1(ale ~Phite ,,,,oowEOp a„o„cEO dune 1 1886 76
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p 1 a i p I ~ IOa. USUAL OCCUPA710N (OIK t~i6I0/ICOIR IOf1f KINDOF ~Ujj1~S50R IjIDVSTRY 11. ~~RTMPI.ACE (ST~tt 0? /Ottl/R COat~lt?~) 12. CITTlEM Ci MW1T OOUNTRYT
ri~h p~r- lrita/~o nakht0l~jr,t~snlJ~elfret) j, O t3<l. OI USA
..n.ae Ma~ntenanca ~~~c Instruc. Chica Illinois
blact Snk ~3, fATNER'S NAME 14. MdTaER'S MAIDEN IMME
t~p~rrlt~r ~1111 Knierin Elizabeth Kae le
~ 1S- MAS DEGEASED EVEk IN U. 5. AIIMED FONCES? 16. SOCIAI SECURITY l10. D. IM • s1YMATYw[
(Yr. r. r rrkw~+.) (fl ra. n~. w~ ~M+ a1 r~~r1
m 3~9-~'-92E9 ~u?~•• t. ierce a.
r~n. ~.a c~vsi o~ ~urK o~tr a.e ca~,e yn ta,~ c.>. te~..+,~ ca.1 INTERVAL OETK'EEq
. d 1 ro e t o ~ ?ART 1. pEATH wA5 C11USE0 ~T: ~ 016ET ANO DEATN
ruse tsi• IMMEDIATE CAU3E ~I~j'S`_-i~l
n.II1S of Stomach 2~ears
tA• e~r-
' t l f l e~!• Con~itls~l, iJ ~w/. WE TO (b)
•ith Ch• r~AkA /ps ~uy W
1 o e a 1 o8ovt etttat
~ r• i~~r~r K~I /As Kw/n• . _ Y _
slthln TZ a ~I~ c~~+K laaf. ~E TO (t)_
O ?ART 11. OTli/t SKMlKAM ['AMOITI0115 CGKi1dMlftMC TO OUTM 7U~ MOT 11ELATED TO TME TERtliW1L [MS[ASE CON01TtON GIYEM IN tART 1(t) . WAS AL'TOKY
Ifour~ •f- ~ ?ERFORMEDI
t~r d~~th i
Y r¢5 ? no m
' or b•for• ~ t pf$('RI~ HOYf IMJUR~ OCCURRED. (Erttf Ref~rt oJiw/n~f !q PQrt 1 or Past I! 0/Gem 111J
¦atfA~ anJ ~ ACCIDEN7 SUICIOE HOMICIOE
d~•p~•~_ a o a
tlop ot TiME OF Hor? Aloe~fA. M~r. Yw
bodr. ~1UURr w~.
a p. at.
s ZOt. IMJUIIY OCCURRED 2Dt. ~CE 9F IIWURY (s. i~ W~+s~l MOtwt, 20J. CITY, TOWM. OR LOCATIOM COUNTY STATE
wHx~ ~t ~ MoT ~w?u~ ~ l+~+~. f«ior~..r,eet. o~in otM., etc.)
WORK AT WWIK
21. 1~tt~nd~d t!» d~asd /rom _ ~ . t+a Si1.~62 •nd lut w~v h~~ ~tir~ on S~L~-
DMth occurrsd ~f • .r. on th~ d~t~ ~Nbd ~6wr ~nd to th~ b~st o/ mr knowl~dN, from th~ wuM~ atat~d.
~11 it~~• }2s. SMIM7llw~ (GH?ssOS tNk) IIb. ADORE55 22c. DATE 516ME0
L~ e• Tart Pierce Fla. 6 7$ 62
corpl~t• • ftussell L. Counts M.D.
_ tGtu~atl. Lyy. DATE 29c. 11AME OF CEMETFIIY OR CREMAT611Y 23~. LpCATqN (Clft. lo~v71. 0~ tl~fU/3
j Rem~va~s~"`n' Jun~ 77 1952 St. 's Ceraeter Chica o
V. 9. /611 j;, iVMERAI DI E dt'S SIGNATUR~ ~SA r 1111eI~~ HO81@ ~~TE RECO. /Y LOCAL REG. 26. RES~STRAR'S 41C ~ ^
~.•.loaa Joaeph W. Yates i~t. Pierce Fl.a. b 2g 62 Anna L~e Denison d.r ~