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I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I <br />UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH <br />DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I <br />ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR <br />HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY -IN -FACT, MY <br />PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I <br />ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR <br />HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE <br />CONFIRMED BY A SECOND PHYSICIAN. <br />Witnessed by: <br />STATE OF NEBRASKA <br />COUNTY OF HALL <br />GENERAL NOTARY- State of Nab <br />JOHN M. CUNNINGH <br />My Comm. Exp. Nov. 22, 2007 <br />201303382 <br />OL Z, Pr; cipal <br />DECLARATION OF WITNESSES <br />We declare that the principal is personally known to us, that <br />the principal signed or acknowledged her signature on this Durable <br />General and Health Care Power of Attorney for health care in our <br />presence, that the principal appears to be of sound mind and not <br />under duress or undue influence, and that neither of us nor the <br />principal's attending physician is the person appointed as <br />Attorney in Fact by this document. <br />s s. <br />Date <br />q/ <br />Date <br />IN WITNESS WHEREOF, I have hereunto subscri <br />affixed my official seal the da - d'.r las - •T <br />411 ir <br />Print Name of Witness/ <br />4,/ .... <br />Pri ted Name of W tness <br />LILA J. BOLTZ being the named principal, who is to me known <br />to be the person described in and who executed the above Durable <br />General and Health Care Power of Attorney, acknowledges the same <br />to be her voluntary act and deed. <br />my name and <br />ve written. <br />