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, . . _.�� "` __ __ - --- ...._�- :��.. � _..._�_�-- . . _. --,�_�.--- . _ .. ---. _.�___--- - -- ---- . ,r�e.Re��-._.,�... _�._.-- _ _ ^ _ ' . .- . • • 9?-� sc)�",�39 us�a�as=o�t or �x�aasa �To d�olr�rc that th� pri.ael.�r,1 ie �er�analiy kaown to u�i �h+►� tb� �_ priacipal ■iqa�d or acknoWl�dg�d hi• or h�r �igaatur� on thi� po�r��;�Q � o! attora�y !or h�aLtb aar� ia our pr��nc�i that th� prinaipal app souac3 aind and not uad�r dur��■ or undu� inllu�aa�t �d tbat th� p�r�oa ap�o3.at�d h�r�ia a� th� priaoip�►1�■ attorn�y 3n laot, by thi• doou�nt, is not on� o! th� lolloxl.nq d�sorib�d p�r�ons, to-wit: on� ot th� witn��sn b�r�in� th� prfaoip�l•� att�ndi.nq phy�ician= an smployaa o! tho a�t�ndinq pby�iai+�n Nho i� unr�lat�d to th� principal by blood, ma�riag� or a�doptioni a p�r�on unrolat�d to th� prinoipal by blood, narriaq� or adnption, wha is an owu�r. op�z:tor or �ap].oy�� of a h�altts ou� provid�r in or Mhi.�h tih� prinaipal i� s pati�ati or r��id�at� or w p�r�on who i� unr�laC�d to th� principal by blood, s�srriaq� or adoptioa and �ho is pr��ntily •�s�►inq a� an attorn�y in lao� tosr twa or �oor� prinaipals. K� �urth�r Q�clar� that n�ithas of u� witas��os a�r� the prinaipal•• Bpov�so, pauaat, obild, qrandohi.ld, sibling, pr��umptive h�is, kao�m d�vis�� st �� tiv� c! thir vita�s�ing, att�aditt.g phYpioian, attosa�y in faot, or an w�ploy�� of s lifo or h�alth insurance provid�r !or th� principal. �io aor� tbua on� wi.tn�a is aa admiai�tratos or emplcr�+e� ot a hoal�h osr� provid�r who i• aariag !or or tr�atiay th� priacipal. liitnua�d Sy: n_��. � G� ��i��'��.-��-9..1� �� i��`%��. � , � ..v-y� . - •- -- S uatur� oi N ta��/Dat� Pr�.n d Naa� of Ni nsss oC� /��;�,�.-�, Sh ct.ro n � • �� I GI-- siqu ti�ur� of Hitn�sr/Dat� Pr3.aC�d Na� of xita�ss �� so r�sar aacors�c a roKaA or arro�na: ro� ��ea ca�s Tbi• i• aa isnportianL l�qai dooum�nt. it ar�at�� a powr o� attorn�y !or h�alth aas�• B�tor� ��qaiag thi.s dooum�at you �hould kno++�th�n i�poztanti , lact�: (a) Thi� doattaa�at qiv�■ th� p�r�oa yau d�siqnat� a� your attosn�y in laaL th� por�r to malc�h�alth oar� d�aisions tor yoa vh�n you ar� det�zain�d to � iacapabl�. 1►lthough aot n�c�s�ary and a�ith�r •aaousaq�d nor disaouraq�d, you �►ay wi�h to stst� ia�truationa or Mish�■ and liait th� authority of your attorn�y in factj (b) Bubj�at ta tb� linitatioa stet�d in subdivisioa �d) of this docu�at, th� p�r�on you d�aaiqaat� a� yous attorn�y ia fact haa s du.ty to act coa�ist�atly rith your dair�� as �tat�d in thi.� docun�nt or oth�svia� mad� kaoxn by you or, it your d��ir�s ar� uaknon�n. to aoti in a maaa�r ooasi�t�r�t �ith ycur b��t iat�r�str. Th� g�s�on you d��iqnat� ia this docum�nt do�s. how�N�r, hav� th� riqht to virhdrar lra� this duty at any tinst (c) You ruy �y�cify that any d�t�s�ti.nation that yon ar�inaap�bl� o! ukinq hwalth car� d�oioions must ]a� aonfirm�d by a ��cond phy�iciaaf (d) Tho psrson you d��igaat� as your attornoy in lsat will aot hare th� authority to con�onC ta t8� withholdiag or witltdrawal o! lif�-ouotain3.ng proc�dur�� or af artificially acloiai�t�r�d nutrition or hydration ual�s• you giw hia� or h�r that authority i.a tbis po�»r o! attoza�y for h�alth oar� os in �om� oth�r al�ar and aoavinaing a�ann�r; �.a_ _�..�� • •�..�.*�o f�� t��t�t� nar� ahnuld b� r�vi�lT�d ��j �as�• p....�. C. G��..�J por�odically. Zt will aoatiau� in �!l�at indolinit�ly ual��s you�x�rais• your riqht to r�vok� it. You hav� th� right to r�voko this p+o�ar ot attora�y at aay t� wbile you u� aom��t�ati by notifyiag th� attorn�y ia facL or your h�a�l,th car� pronidor o! th� r�voaatioa orally or ia writiagj (t� �opit4 a,ny provi�ion� ia thia pow�r ot attorn,y for h�altih oar�, yau haw th� riqht to mak� h�alth aeir� d�cisions for yoursvlf as loaq a� you ar� not iacapabl� o!maltiaq tho�• d�af�ion�= and �q) Si th�r� i� anything in thi� pox�r o! attorn�y tor h�alth car� paqo 1 0! 3 paqta