(A) The written declaration described in section 2108.70 of the Revised Code shall include all of the following:

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(1) The declarant’s legal name and present address;

(2) A statement that the declarant, an adult being of sound mind, willfully and voluntarily appoints a representative to have the declarant’s right of disposition for the declarant’s body upon the declarant’s death;

(3) A statement that all decisions made by the declarant’s representative with respect to the right of disposition are binding;

(4) The name, last known address, and last known telephone number of the representative or, if the representative is a group of persons, the name, last known address, and last known telephone number of each person in the group;

(5) If the declarant chooses to have a successor representative, a statement that if any person or group of persons named as the declarant’s representative is disqualified from serving in such position as described in section 2108.75 of the Revised Code, the declarant appoints a successor representative;

(6) If applicable, the name, last known address, and last known telephone number of the successor representative or, if the successor representative is a group of persons, the name, last known address, and last known telephone number of each person in the group;

(7) A space where the declarant may indicate the declarant’s preferences regarding how the right of disposition should be exercised, including any religious observances the declarant wishes the person with the right of disposition to consider;

(8) A space where the declarant may indicate one or more sources of funds that may be used to pay for goods and services associated with the exercise of the right of disposition;

(9) A statement that the declarant’s written declaration becomes effective on the declarant’s death;

(10) A statement that the declarant revokes any written declaration that the declarant executed, in accordance with section 2108.70 of the Revised Code, prior to the execution of the present written declaration;

(11) A space where the declarant can sign and date the written declaration;

(12) A space where a notary public or two witnesses can sign and date the written declaration as described in section 2108.73 of the Revised Code.

(B) A written declaration may take the following form:

APPOINTMENT OF REPRESENTATIVE FOR DISPOSITION OF BODILY REMAINS, FUNERAL ARRANGEMENTS, AND BURIAL OR CREMATION GOODS AND SERVICES:

I, _________________ (legal name and present address of declarant), an adult being of sound mind, willfully and voluntarily appoint my representative, named below, to have the right of disposition, as defined in section 2108.70 of the Revised Code, for my body upon my death. All decisions made by my representative with respect to the right of disposition shall be binding.

REPRESENTATIVE:

(If the representative is a group of persons, indicate the name, last known address, and telephone number of each person in the group.)

Name(s): __________________________

Address(es): __________________________

Telephone Number(s): __________________________

SUCCESSOR REPRESENTATIVE:

If my representative is disqualified from serving as my representative as described in section 2108.75 of the Revised Code, then I hereby appoint the following person or group of persons to serve as my successor representative.

(If the successor representative is a group of persons, indicate the name, last known address, and telephone number of each person in the group.)

Name(s): _________________________

Address(es): _________________________

Telephone Number(s): _________________________

PREFERENCES REGARDING HOW THE RIGHT OF DISPOSITION SHOULD BE EXERCISED, INCLUDING ANY RELIGIOUS OBSERVANCES THE DECLARANT WISHES A REPRESENTATIVE OR A SUCCESSOR REPRESENTATIVE TO CONSIDER:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ONE OR MORE SOURCES OF FUNDS THAT COULD BE USED TO PAY FOR GOODS AND SERVICES ASSOCIATED WITH AN EXERCISE OF THE RIGHT OF DISPOSITION:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DURATION:

The appointment of my representative and, if applicable, successor representative, becomes effective upon my death.

PRIOR APPOINTMENTS REVOKED:

I hereby revoke any written declaration that I executed in accordance with section 2108.70 of the Ohio Revised Code prior to the date of execution of this written declaration indicated below.

AUTHORIZATION TO ACT:

I hereby agree that any of the following that receives a copy of this written declaration may act under it:

– Cemetery organization;

– Crematory operator;

– Business operating a columbarium;

– Funeral director;

– Embalmer;

– Funeral home;

– Any other person asked to assist with my funeral, burial, cremation, or other manner of final disposition.

MODIFICATION AND REVOCATION – WHEN EFFECTIVE:

Any modification or revocation of this written declaration is not effective as to any party until that party receives actual notice of the modification or revocation.

LIABILITY:

No person who acts in accordance with a properly executed copy of this written declaration shall be liable for damages of any kind associated with the person’s reliance on this declaration.

Signed this ______ day of_______

_____________________________

(Signature of declarant)

ACKNOWLEDGMENT OF ASSUMPTION OF OBLIGATIONS AND COSTS:

By signing below, the representative, or successor representative, if applicable, acknowledges that he or she, as representative or successor representative, assumes the right of disposition as defined in section 2108.70 of the Revised Code, and understands that he or she is liable for the reasonable costs of exercising the right, including any goods and services that are purchased.

ACCEPTANCE (OPTIONAL):

The undersigned hereby accepts this appointment as representative or successor representative, as applicable, for the right of disposition as defined in section 2108.70 of the Revised Code.

Signed this ______ day of ________

____________________________

Signature of representative (if

representative is a group of persons,

each person in the group shall sign)

Signed this ______ day of _______

__________________________________

Signature of successor representative

(if successor representative is a

group of persons, each person in the

group shall sign)

WITNESSES:

I attest that the declarant signed or acknowledged this assignment of the right of disposition under section 2108.70 of the Revised Code in my presence and that the declarant is at least eighteen years of age and appears to be of sound mind and not under or subject to duress, fraud, or undue influence. I further attest that I am not the declarant’s representative or successor representative, I am at least eighteen years of age, and I am not related to the declarant by blood, marriage, or adoption.

First witness:

Name (printed):

_______________________ Residing at: ____________

Signature: ____________

____________________________ ____________

Date:

____________________________

Second witness:

Name (printed):

____________________________ Residing at: ____________

Signature: ____________

____________________________ ____________

Date:

__________________________

OR

NOTARY ACKNOWLEDGMENT

State of Ohio

County of _____________ SS.

On _______________, before me, the undersigned notary public, personally appeared _________________, known to me or satisfactorily proven to be the person whose name is subscribed as the declarant, and who has acknowledged that he or she executed this written declaration under section 2108.70 of the Revised Code for the purposes expressed in that section. I attest that the declarant is at least eighteen years of age and appears to be of sound mind and not under or subject to duress, fraud, or undue influence.

Signature of notary public

__________________________

My commission expires on:

__________________________

(C) Completion of a federal Record of Emergency Data form, DD Form 93, or its successor form, by a member of the military, is sufficient to constitute a written declaration under section 2108.70 of the Revised Code if section 13a of DD Form 93, entitled “Person Authorized to Direct Disposition,” has been properly completed by the member of the military who has subsequently died while under active duty orders as described in 10 U.S.C. § 1481.