Laserfiche WebLink
I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I <br />UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND <br />DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH <br />DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF <br />ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY <br />ATTORNEY -IN -FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A <br />PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN <br />THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY <br />INCAPACITY IN THE FUTURE BE CONFIRM BY A SECOND PHYSICI <br />WITNESSED BY: <br />Signature of Witness�b *t <br />W <br />DATED: Jul eV, 2012 <br />DECLARATION OF WITNESSES <br />We declare that the principal is personally known to me; that the principal signed <br />or acknowledged his signature on this Durable Power of Attorney and Power of Attorney <br />for Health Care in our presence; that the principal appears to be of sound mind and not <br />under duress or undue influence; and that neither of, nor the principal's attending <br />physician, is the person appointed as attorney -in -fact by this document. <br />\ randd,' ; a h J <br />(Printed Name of Wi <br />Li)VioThiedui <br />(Printed Name of Witness) <br />201210053 <br />