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"'P WILLIAM F.tiRL WHITESELL 3iale ~ A~~ust 15, 198b
awCE e~'~IY~~te But• AGE - l»+ B.r.r~~ ` UNOER i'/EAR uNDEH t OAV OA*E tK B~Aie~rYO O+~ Y~ 1 COUNTY pF DEA7N
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„ Vero Beach Inclian River Memorial Hospital „ Inpatient
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, New Jerse , U.S.A. ,aMarried „ Alar Athelene Head
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RES~OENCE-STAtE COUNTII C1TY. TOVYN Qq LOCATION SiREET Al~q HUYBER INSIOE GTV LfY1T$
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,.,Florida St. Lucie ,.~ort Pierce 7604 Arthurs Road No
~ FATHER-NRME flqST Mi00lE LA57 MOTM~R-IJAIpQNNA4E FIRST 4~O~I.E LAST
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_ ,,,Mary A. Whitesel_1 „0 7604 Arthurs Road Fort Pierce, Florida 3345L
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_ ,,,Cremation „~aisley-Hobbs Crematorium ,K Fort Pierce, Florida
= cun~a.~ a+-,ss~.~ , ~ FUwEr.~~ HO~+E AQCRES$ 301 S Ukeechobee Road
- ~ ~J~ iiaisley-Habbs Funeral Home Ft.Pierce,F1a.33450
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1~~~h1 ACGOENT SUIC~OE d DATE ~ IWURY (MO , Dly, Y~ ) HOUq O~ iNlVpV UESCp7Hf MOW INJVii~ OCCURAEO
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kRS Form 512. ?io z~c y a~a
~H~VNY AT WORK (Spc•/r otACE Qf nVJURY-Atl+dn! ~um ytreet 4ctory. Offete LCCATIOtti STREET QR R i D NO CIT~ Qq TOWN STATE
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"I NEZEBY CERTIFY THE ABOVE TO BE A TitUE AN~ CORRECT COPY OF THE IOCAL REGISTR~IR'S
RECORO ON FILE IN THf_ INDIAN RIYER COUNTI PUBLIC t'EALTN UNIT AT VER(i 6EACH, ~LORIDA."
THIS IS NOT YALIp UNLESS TNE RAI~ED SEAL Of THE INDIAN RIVER PUBLIC HE H UNIT
IS AFFIXED. .
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AU" '9 ~1 ~37 A I, UMTY HEAL DIR OR/REGISTRtiR
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J~ N. L~W , C IE DEHUTY REGIST(tAR
~ e0o~ 511 PA~ 928
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