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HomeMy WebLinkAbout4-12-01Certificate No. 2261 (CITY OF SEBASTIAN Certificate of Interment Rights IN ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Debra Coburn 4235 5th Street, Vero Beach, FL 32968 (name) (address) In and for consideration of the sum of $1,000.00 is entitled to full interment rights in the Sebastian Municipal Cemetery for the following lot: Unit 4, Block 12, Lot 1 of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 4th day of June, 2010. CITY OF SEBASTIAN, FLORIDA ATTEST: AI Minner City Manager Sall Maio, MMC City Clerk In Memory of Samuel "Sam" E. Coburn August 28, 1956 - June 02, 2010 Samuel "Sam" E. Coburn, 53, of Vero Beach, FL passed away Wednesday, June 2, 2010 at the Indian River Medical Center. Sam was born August 28, 1956 in Brooksville, FL. The son of Eugene and Louise (Smith) Coburn, he graduated from Hernando High School before attending Gupton -Jones Mortuary School. After serving funeral homes in the Tampa and Brooksville area he moved to Indian River County where he met and wed his beloved wife Debra Jones. Sam had been currently serving as the Managing Funeral Director of the Seawinds Funeral Home in Sebastian of which he had been instrumental in its start -up and had worked closely with developing the growth of Cox- Gifford- Seawinds and Davis - Seawinds Funeral Homes. He was fondly recognized as an avid fisherman and sportsman, participating in many fishing tournaments and softball leagues across the years. He had been active in the Sebastian Golf Club, Sebastian Rotary Club of which he was a Paul Harris Fellow, Sebastian Elks Lodge, Vero Beach Kiwanis Club, and had served as President and coach of the American League of the Little League Baseball in Indian River County. Sam would extend his helping hands to all and he was enriched with many friends. Survivors include his wife of 27 years, Debra Coburn of Vero Beach, son Joshua Coburn of Vero Beach; mother Louise Emm (Robert) of Vero Beach; sister Susie Johns ( David) of Vero Beach; brother Leslie Coburn (Gina) of Vero Beach; sister Beverley Wetherell of Indiana; brother Tim Coburn of Brooksville, FL; mother in law Gladys Jones of Vero Beach; sister in law Darlene Basden of Vero Beach; brother in law Ray Jones (Kim) of Sebastian; numerous nieces and nephews. He was predeceased by his father Eugene Coburn. Name_ .�!� ��-- �Q- -S/,e * "7 SC Unit 1 Block!_ Lot Date of Mark -out 3110 Date of Burial ! L,; ' Time SODA h14,44 A Name of Funeral Home 3 Authorized by CITY OF SEBASTIAN CITY CLERK'S OFFICE 4697 RECEIPT Name (� X 10 rci /Coburn ❑Cash Date +� ' Check # Z t 'IqS No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 Copies/Bid Specs. 001501 341910 LDC/Code of Ordinances 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots /000 , 00 LottNiche I Bb& (Z Unit 001501 343805 Cemetery Fees J -5o • o O FLORIDA DEPARTMENT OF HEALT A /TVDC\ State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL - TRANSIT PERMIT A f I 1. Name of First Middle Last Date Month Day Year Deceased SAMUEL COBURN of JUNE 2 2010 Death 2. Place of Death City, Town or Location Name of (If neither, give street address) County INDIAN RIVER / VERO BEACH Hosp. or INDIAN RIVER MEDICAL CENTER Inst. 3. Name of Medical Address Phone Number Certifier NOOR M. MERCHANT, MD 1880 37TH STREET, SUITE A Medical Examiner FlPhysician VERO BEACH, FLORIDA 32960 772 - 567 -2332 4. Name of Funeral Home /Direct Disposal Address Fla. Lic. No. /Reg. No. Phone No. (Area Code) EstablishmentCOX— GIFFORD— SEAWIND 1950 20TH STREET FUNERAL HOME & CREMATORY VERO BEACH, FL 32960 40816 772 - 562 -2365 5. Check a. The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b. ® DR. MERCHANT was contacted on JUNE 3, 2010 He /she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that will complete and sign the medical certification of cause of death within 72 hours. Eml was contacted on He /she verified that , Medical Examiner, will complete and sign the mtojr,al certification of cause of death within 72 hours. 6. Funeral Director/ ignature F.E. No. /Reg. No. Date Signed t Direct Disposer ( `i//"� F042919 6/3/2010 B. / 03JURIAL - TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 10- 40816 -254 ❑X A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has been contacted by the funeral director and will not be able to complete the medical certification of cause -of -death section of the death certificate within 72 hours. No extension of time for filing t e da ce ificate ha ben requested. Registrar or ( Date Date Certificate Subregistrar Signature Issued: 6/2/2010 DUe: 6 /14/2010 C. AUTHORIZATION for CREMATION, DISSECTION, or BURIAL -AT -SEA Approval Number: Date Medical Examiner, , gave authorization by telephone to Funeral Director /Direct Disposer. Date The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after death is required for all cremations. D. CEMETERY OR CREMATORY Method of Disposition: Place of Disposition s�f,3 .4s" ,11 A( XXBURIAL ❑STORAGE Date of Disposition � Z CREMATION Signature of Sexton 1 or Person -in- Charge J? EJOTHER (Specify) This permit must be endorsed by the Sexton or person -in- charge (or by the Funeral Director /Direct Disposer when there is no Sexton) and returnea within 10 days to the local County Health Department in -the county where disposition occurred. Distribution: white: Cemetery or Crematory DH 326, 8197 (Obsoletes all previous editions) Yellow: Funeral Director or Direct Disposer (Stock Number: 5740 -000 -0326 -2) Pink: Local Registrar Re yckd `i► rya City ©j SebastiaH Sebastian Cemetery Pb. # 1(772) 589 - 2545 Fax # 1(772) Note This Is for Informational purposes reguarding Monuments at Sebastian Cemetery Note Dry Mix Please return to Sebastian Cemetery Foundation noured 1921 North Central Ave. bv: herman 32958 Attention Cemetery Sexton date : 8/26/10 stone installed by: herman Size 1 -Ox2-OxO-4 standard - Bik. granite flat grass marker - - vase date - 8/26/10 Names& Dates: His: sam E. coburn Her: D.O.B. 1956 D.O.B. D.O.D. 2010 D.O.D. Legal Description; Unit 4 Blk.: 12 Lot : I Approved By: K . G . K K.G.K. Checked By: Date : 8/26/10 Example: By : Eagle 4 "deep � A �_j 12"