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IN WITNESS WHEREOF, I have executed this document this <br />day of September, 2006, at Grand Island, Hall County, Nebraska. <br />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 PHYSICI <br />Witnessed by: <br />01:4 j /Mte / e 4 ( , : <br />Signattre of Witness <br />( .6/4We-hit V.CAR <br />Sign ure of Witness Date <br />STATE OF NEBRASKA ) <br />) ss: <br />COUNTY OF HALL <br />201109274 <br />CARLIT J. ±CHEL, Principal <br />DECLARATION OF WITNESSES <br />Date ���� <br />-5- <br />201705966 <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 in our presence, that <br />the principal appears to be of sound mind and not under duress or <br />undue influence, and that neither of us nor the principal's <br />attending physician is the person appointed as Attorney in Fact by <br />this document. <br />Sheryl Schilowsky <br />Printed Name of Witness <br />Stephanie L. Ounsombath <br />Printed Name of Witness <br />CARLITA J. MICHEL, being the named principal, who is to me <br />known to be the person described in and who executed the above <br />Durable General and Health Care Power of Attorney, acknowledges <br />the same to be her voluntary act and deed. <br />