LaFera, Thomas - a � , , ;- '. . STATE OF ARKANSAS _ • '' ��, .�
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ARKANSAS DEPARTMENT OF HEALTH
Er' Vital Records f i
1
9 7 a s re n CERTIFICATE OF DEATH FILE NUMBER 2018012658
I DECEDENTS LEGAL NAME(Inolude AKA's if any)(First Midge Last,Suffix) : 2.SEX 3a.DATE OF DEATH 3b.TIME OF DEATH
t�;' THOMAS J LAFERA MALE MAY 28,2018 05 30 AM ,
4.SOCIAL SECURITY NO. Se.AGE Last Birthday 5b.UNDER 1 YEAR 5c.UNDER 1 DAY 6.DATE OF BIRTH 7.BIRTHPLACE(City and Stale or Foreign Country)
r
' 056-20-8464 (Years) Months Days Hours Minutes NOVEMBER 15,1928 GLENS FALLS,NY '
89
8a RESIDENCE STATE or FOREIGN'COUNTRY 8b.COUNTY 8c.CITY OR TOWN
1......:„.---
�'' o ARKANSAS BENTON BENTONVILLE
k U 8d NUMBER AND STREET 8e.APT.R NO. Bf.ZIP CODE 8g.INSIDE CITY UMI7S? _:_
L'Ij505 SW SIMS DR 72712-3747 YES
..-, o '9 EVER IN US ARMED FORCES? 10.MARITAL STATUS AT TIME OF.DEATH 11.SURVIVING SPOUSES NAME Of wife.give namepnor to first mamaga) .4
cc YES
a WIDOWED(NOT REMARRIED)
z i 2a IF DEATH OCCURRED{N A HOSPITAL 12b.IF DEATH OCCURRED SOMEWHERE.OTHER THAN A HOSPITAL 12c.COUNTY OF DEATH
r NURSING HOME/LONG TERM CARE FACILITY BENTON \•
2 12d FACILITY NAME(8 not institution,give number 8 street) 12e.CITY OR TOWN 121.ZIP CODE
,tr;-
APPLECREEK NURSING AND REHAB CENTERTON 72719 .
13 FATHER S NAME(First,Midge,Lest) 14.MOTHERS NAME PRIOR TO FIRST MARRIAGE(First,Midge Last)
JOHN LAFERA MARY PATNOD i
!,•i; v '15a.INFORMANTS NAME 15b.RELATIONSHIP TO DECEDENT 15c.MAILING ADDRESS(Number and Street or PO Box,City,State,Zp Code)
1tt� a THOMAS M LAFERA SON 505 SW SIMS DR,BENTONVILLE,AR,7 2 71 2-374 7 ''
U 16a METHOD OF DISPOSITION CREMATION /;
16b PLACE OF DISPOSITION(Name of cemetery,crematory other pace): 16c.LOCATION CITY.TOWN,AND STATE
�,4, F BENTON COUNTY MEMORIAL PARK CREMATORY ROGERS,ARKANSAS
ki• I7a.EMBALMER S NAME : 17b.EMBALMERS I7c.SIGNATURE(FUNERAL SERVICE LICENSEE OR OTHER AGENT)
NOT EMBALMED LICENSE# Is, MAT73(EW L R.USSELL
0 17d,NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY 17e,>LICENSE-#
t' BENTON COUNTY MEMORIAL PARK 500
3800 WEST WALNUT,ROGERS,AR,72757
r '4 lea.DATE PRONOUNCED DEAD '18b.TIME PRONOUNCED DEAD 18c.NAME AND TITLE OF PERSON PRONOUNCING DEATH(PRINT/TYPE) t9.WAS MEDICAL EXAMINER? - `
Illi
MAY 28,2018 05:54 AM WESLEY LEWIS,DEPUTY CORONER OR CORONER CONTACTED?
r YES
CAUSE OF DEATH (t�
20.PART 1 Enter the chain of events diseases,injuries,or compkcations that directly caused the death.DO NOT enter terminal events such as cardiac arrest. j APPROXIMATE INTERVAL: 1,1{
respiratory arrest,or ventricular hbnllatfon without showing the etiology.DO NOT ABBREVIATE.Enter only one cause on a line. iOnset to Death
rIMMEDIATE CAUSEr(Final dlsease:or condition ... - a. PNEUMONIADAYS
� Se uenem death) Due to,r as a�wance o0 - '
,it resulting �,
�1 i q aly Net conditions, b. FEMUR FRACTURE WEEKS /'
deny,leading to the cause Du°m;ras a,wr wmxe of) i
listed on •
line a.Enter the 1 4
l s cc UNDERLYING CAUSE o- FALL. ' WEEKS
X,`k' t - p :(disease or injury that Duet es a
cc initiated the events consequence 00
f v resulting in death)LAST,. d I
I U PART II.Enter other siondicant conditions contributino to death but not resulting in the underlying cause given in PART I. 21a.WAS AN AUTOPSY PERFORMED?
o NO to
Z, 21b.WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE : \;
THE CAUSE OF DEATH?
1 t y 22.MANNER OF DEATH ACCIDENT
t; 1 23.DID TOBACCO USE CONTRIBUTE TO DEATH? 24.IF FEMALE 1
1 UNKNOWN
' f+ , 25a DATE OF INJURY(Ma/Day/Yr) 25b.TIME OF INJURY 25c.PLACE OF INJURY(e.g Decedent's home,coratwceon site,restaurant wooded area) 25d.INJURY AT WORK?
Ij+ 05/28/2018 UNKNOWN RESIDENCE NO r
U 25e LOCATION OF INJURY(Number Street Apartment No.,City State Zip Code) :: 1570 W CENTERTON BLVD ,
i�t!'' CENTERTON,AR 72719-8712
,s`i ,,, 25f DESCRIBE NOW INJURY OCCURRED: : 25g.IF TRANSPORTATION INJURY,SPECIFY
�� FELL HOME X'
13. 26a.CERTIFIER(Check only one)
is _ ❑ Coroner On the basis of examination and,or investigation,in my opinion,death occurred at the mme,date,and place,and due la the causes(s)-:and manner stated.
i:• SIGNATURE. /el TIN,4 LOUISE WARD TITLE DEPUTY CORONER DATE. MAY 30,2018
- 26b.NAME AND COMPLETE MAILING ADDRESS OF PERSON SIGNING ITEM 26a.(Type/Pint) 26c.LICENSE*
=z" TINA LOUISE WARD,DEPUTY CORONER
203 EAST CENTRAL SUITE 105'BENTONVILLE AR,72712 .\
4; -, 27a.SIGNATURE OF REGISTRAR - 27b.FOR REGISTRAR ONLY-DATE FILED
b INOTES
0- � MAY.30,2018
AMENDED ITEMS: -
0';\
�; • ���p�TME4/,k%i THIS IS TO CERTIFY THAT THE ABOVE IS A TRUE AND CORRECT COPY OF THE CERTIFICATE ON
E- - i,,co ... "•%..,:, ��8,, F)LEIN THE ARKANSAS DEPARTMENT OF'HEALTH.
f 'S 11 tl ' = -- 6037127
r a i 'SEAL $-1 : �/ �/ t� /� /{ Q Shirley Louie
0/ tS i MAY u v 201 State Registrar
. = 6037127
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II (III I'lllll I) Ilil�l
��".F RQCK1 PQ I A REPRODUCTION OF THIS DOCUMENT RENDERS IT VOID AND INVALID.DO NOT ACCEPT
'� �� ,:. WARNING: UNLESS EMBOSSED SEAL OF THE ARKANSAS DEPARTMENT OF HEALTH IS PRESENT. -: /,
•.'G`': IT IS ILLEGAL TO ALTER OR COUNTERFEIT THIS DOCUMENT. VR-112
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THE FACE OF THIS DOCUMENT HAS A COLORED BACKGROUND ON WHITE PAPER.THIS IS WATERMARKED PAPER.DO NOT ACCEPT WITHOUT FIRST HOLDING TO LIGHT TO VERIFY WATERMAR
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T1 v� to- ce,rti fy that the. retn, of C,1 f(i ;
Thonta4-j. Larterct. k
1 Who-d ed Jet 2 8 2 0I 8 %w C ay R at the aife,of 89,
were/th 4 day crervcated,at our crematory with.the observa rice
of ail legal/re,quzreme nt
I 8 County Me4no-ricaPark., INC.
0 '
vt Date
0 L �ut3�o�-sty K rs�.+i.ta.t'w�
5/30/2018 c
LaFera
NAME Thomas J LaFera L� Age: 89
Lot Owner: Thomas J LaFefa
Lot# Mohawk 37 Grave#
Case: Urn
Died: 5.2 8.2 01 8 Interred: 9 .2 9.2 2
Funeral Home: Benton County Memorial Park Cremator
Cemetery: Arkansas
Pine VIew
LAFERA
Owner
Thomas J. LaFpra
Address Plot
5 Brookwood Dr. Glens Fa11 , NY 12801 Mohawk
Phone # Lot #
37
Deed # Date
1762 4.28.83
Cost Foundation Y - N
$600.00
Location
North-Vacant
South-Vacant
West-Vacant
East-Fish/Jacox
Remarks
Record of Interments
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