Royal, Jacquelyn Anne Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: fAt'C1 T01) RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: Oh iii 2:3001
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
AB0vprR (1AVIE
NAME: IACQ01.1A E POOL CASE # Ge
TYPE OF CONTAINER: ` 6,71.f J 4-105/14ti '
PLACE OF DEATH: 1lS L)r- ( -r /f 47 - (1,21Loret lef 7ii wood Worn
ESTIMATED WEIGHT OF REMAINS & CONTAINER I yS— /L S /AGM d!s
PLACED IN HOLD: 2, itof I y
PLACED IN REFRIGERATION:
DATE OF CREMATION: I 1 ZO I Z( c7
TIME STARTED: l 301001TIME COMPLETED: 1 , 3SAtis
PLACED IN RETORT: 7 %II MOVED: f 170 1 1,/0/17
i
RETORT# IN WHICH REMAINS WERE CREMATED: T'cwite, NIT
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
New York State
Department of State
NEWYORK Division of DIVISION OF CEMETERES
STATE OF One Commerce Plaza
lOPPORTUNITY. Cemeteries 99 Washington Avenue
Albany.NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:1 J18/2021 Number �g
Crematory Name:Pine View Crematorium
Quaker Rd.,Queensbury, .'1'NY 12804 < > 4
Address: Phone: )ta S, t t t j 1 ?
,
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where
they are subjected to intense heat and flame. The heat and flame will incinerate and consume everything except bone and metal,
which are ail that will be left after cremation.
Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
chamber,but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from
the remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechanically
pulverized into small pieces and placed into a designated container or urn. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances,such as to confirm the
identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. if
human remains are delivered In a container which is not suitable for cremation such as ceremonial or rental casket,the
crematory will require that the remains be moved into a suitable container before it accepts the remains. The opening of a
container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased:Jacquelyn Anne Royal Marital Status: Divorced
Last Known Address:31 Knickerbocker St.,Ballston Spa, New York 12020
Place of Death:Glens Falls Hospital, 100 Park Si,. Glens Falls, New York 12801
Sex: D M ®F Age:73 DOB:02/01/1947 Date of Death:01/16/2021 Estimated Weight: 1 ISll b S
Description of casket/container in which remains will be delivered.
Matthews Casket Co. Cremation Case -cardboard top, plywood bottom
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,Initial ONE of the following)
I arrUWe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will1 ntaining directions for the disposition of his or her remains and I/wee are the person(s)having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. MylOur relationship to the deceased is as
follows:
Jacquelyn Anne Royal
(Hans of D.o..,w/
DOS-1898-f(Rev.04/20) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number. 5 Description:brother
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner,
3. Any surviving child eighteen years of age or older,
4. A surviving parent;
5. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased;
8. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act;
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Section 4201(7).
( ALL THREE of the following)
I/We hereby affirm that the body of the deceased does not contain a battery,battery pack,power cell,radioactive implant,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
these Items prior to cremation may result in harm to the crematory and crematory personnel.
I/We affirm that instructions have been given to Cassandra S. Maille
(Fume/Deader Mena)
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
deceased wishes to preserve.
Pine View Crematorium
(Crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
ZIIWe hereby authorize Pine View Crematorium
(Cremeaxy Nerve)
to cremate the remains of the deceased.
(Initial OPTIONAL)
I/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
crematory,if deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
address of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:Carleton Funeral Home, Inc.
Address:68 Main St.,Hudson Falls, New York 12839 Phone:5187474243
The cremated remains of deceased will be disposed of as follows:
Returned to family
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematorium Is authorized to give possession of
(O.melery NM*
the remains to Carleton Funeral Home,Inc. by delivery
(Rawer Home Nerve)
in person or by registered mail. Jacquelyn Anne Royal
(Mew dD.s...o
DOS-1898-f(Rev.04/20) Page 2 of 3
Authorization for Cremation and Disposition
(Initial the following) ,
/JL.. 1/We understand that if the remains are not claimed within 120 days of cremation,
Qjne View Crematorium
may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
((t iti L ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
An urn is not yet purchased. INVe understand that if no urn is purchased or otherwise provided
iPine View Crematorium
will place the cremated remains in
(Nerve d Cnrmatay)
a rigid temporary container for delivery.
This Authorization Form was provided by Cassandra S. Maille was executed at
(Funeral Director Norma)
Carleton Funeral Home, Inc.
(Funeral Ham Name)
68 Main St.,Hudson Falls,New York 12839
(Funeral Hans Addles)
and is signed by the funeral director as witness to its execution.
INVe have received a completed copy of this Authorization Form.
The person(s)identified below is/are the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the forgoing.
Signed
this 18 n day of January 20 21 i,,/47
Typal ? P. /f January
23 p T'...✓.4' /i Dot peal ac. '31-3.-.1. ir
Typed or Printed Name Scrotum
Aafiess
Typed or Printed Name &gneha.
*saws
WITNESS: �)
Cassandra S.Maille 0 ! r
(FueralDit cbrTypedorPrntedNemo) (Furorelobeclor�S4 +m) � /V 14257
(Regishation Nrm berj
Jacquelyn Anne Royal
(Nome of Deesesed)
DOS-1898-f(Rev.04/20) Page 3 of 3