The person solemnizing a marriage shall sign and print or type upon the marriage license a statement, in the form prescribed by the State Department of Public Health, showing all of the following:

1. (a) The fact, date (month, day, year), and place (city and county) of solemnization.
2. (b) The printed names, signatures, and mailing addresses of at least one, and no more than two, witnesses to the ceremony.
3. (c) The official position of the person solemnizing the marriage, or of the denomination of which that person is a priest, minister, rabbi, or other authorized person of any religious denomination.
4. (d) The person solemnizing the marriage shall also type or print their name and mailing address.