Borovsky, Thomas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas James Borovsky Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/4/2018 59 War or Dates n/a
H Place of Death Hospital, Institution or
Z City, Town or Village Moreau Street Address 13 Bluebird Rd
dManner of Death n Natural Cause E Accident ❑Homicide ITC Suicide Undetermined Pending
Iti Circumstances Investigation
W Medical Certifier Name Title
0 Michael Sikirica,MD
Address
Ballston Spa,New York 12020
Death Certificate Filed Distric t u erg Registerj�lumber
City, Town or Village S(J o� 7
®Burial Date Cemetery or Crematory
November 13,2018 Pine View Cemetery —
❑Entombment Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
N C Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
F_- Remains are Shipped, If Other than Above
2 Address
CC
O. Permission is hereby granted to dispose of the human remains scribe abo as indicated.
Date Issued j i f oi/'Qi g Registrar of Vital Statistics 1ditt,((
(( ignat )
District Number `l. Place (�,�4f at /A O )
ll 1 �I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
UJ Date of Disposition 1 1 /1 3/201 place of Disposition Pine View Cemetery Queensbury
(address)
W
Huron 17—A 1
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Connie L. Goedert
Z 1, (please print)
Signature _L ' Q,�0, h.. Title Cemetery Superintendent
(over)
DOH-1555(02/2004)