(A) A cremation authorization form authorizing the cremation of a dead human body, other than one that was donated to science for purposes of medical education or research, shall include at least all of the following information and statements:

1. (1) A statement that the decedent has been identified in accordance with division (B) of this section;
2. (2) The name of the funeral director or other individual who obtained the burial or burial-transit permit authorizing the cremation of the decedent;
3. (3) The name of the authorizing agent and the relationship of the authorizing agent to the decedent;
4. (4) A statement that the authorizing agent in fact has the right to authorize cremation of the decedent and that the authorizing agent does not have actual knowledge of the existence of any living person who has a superior priority right to act as the authorizing agent under section 4717.22 of the Revised Code. If the person executing the cremation authorization form knows of another living person who has such a superior priority right, the authorization form shall include a statement indicating that the person executing the authorization form has made reasonable efforts to contact the person having the superior priority right and has been unable to do so and that the person executing the authorization form has no reason to believe that the person having the superior priority right would object to the cremation of the decedent.
5. (5) A statement of whether the authorizing agent has actual knowledge of the presence in the decedent of a pacemaker, defibrillator, or any other mechanical or radioactive device or implant that poses a hazard to the health or safety of personnel performing the cremation;
6. (6) A statement indicating the crematory facility is to cremate the casket or alternative container in which the decedent was delivered to or accepted by the crematory facility;
7. (7) A statement of whether the crematory facility is authorized to simultaneously cremate the decedent in the same cremation chamber with one or more other decedents who were related to the decedent named in the cremation authorization form by consanguinity or affinity or who, at any time during the one-year period preceding the decedent's death, lived with the decedent in a common law marital relationship or otherwise cohabited with the decedent. A cremation authorization form executed under this section shall not authorize the simultaneous cremation of a decedent in the same cremation chamber with one or more other decedents except under the circumstances described in the immediately preceding sentence.
8. (8) The names of any persons designated by the authorizing agent to be present in the holding facility or cremation room prior to or during the cremation of the decedent or during the removal of the cremated remains from the cremation chamber;
9. (9) The authorization for the crematory facility to cremate the decedent and to process or pulverize the cremated remains as is the practice at the particular crematory facility;
10. (10) A statement of whether it is the crematory facility's practice to return all of the residue removed from the cremation chamber following the cremation or to separate and remove foreign matter from the residue before returning the cremated remains to the authorizing agent or the person designated on the authorization form to receive the cremated remains pursuant to division (A)(11) of this section;
11. (11) The name of the person who is to receive the cremated remains of the decedent from the crematory facility;
12. (12) The manner in which the final disposition of the cremated remains of the decedent is to occur, if known. If the cremation authorization form does not specify the manner of the final disposition of the cremated remains, it shall indicate that the cremated remains will be held by the crematory facility for thirty days after the cremation, unless, prior to the end of that period, they are picked up from the crematory facility by the person designated on the cremation authorization form to receive them, the authorizing agent, or, if applicable, the funeral director who obtained the burial or burial-transit permit for the decedent, or are delivered or shipped by the operator of the crematory facility to one of those persons. The authorization form shall indicate that if no instructions for the final disposition are provided on the authorization form and that if no arrangements for final disposition have been made within the thirty-day period, the crematory facility may return the cremated remains to the authorizing agent. The authorization form shall further indicate that if no arrangements for the final disposition of the cremated remains have been made within sixty days after the completion of the cremation and if the authorizing agent has not picked them up or caused them to be picked up within that period, the operator may dispose of them in accordance with division (C) of section 4717.27 of the Revised Code.
13. (13) A listing of the items of value to be delivered to the crematory facility along with the dead human body, if any, and instructions regarding how those items are to be handled;
14. (14) A statement of whether the authorizing agent has made arrangements for any type of viewing of the decedent or for a service with the decedent present prior to the cremation and, if so, the date, time, and place of the service;
15. (15) A statement of whether the crematory facility may proceed with the cremation at any time after the conditions set forth in division (A) of section 4717.23 of the Revised Code have been met and the decedent has been received at the facility;
16. (16) The certification of the authorizing agent to the effect that all of the information and statements contained in the authorization form are accurate;
17. (17) The signature of the authorizing agent and the signature of at least one witness who observed the authorizing agent execute the cremation authorization form.