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202304679 <br />Surrogate Decision Makinc in Net. xa Nebraska State Unit on Aging <br />SIGNATURE AND ACKNOWLEDGMENT <br />(CAUTION: This document MUST be signed 1N THE PRESENCE of a notary to comply with the Nebraska <br />Uniform Power of Attorney Act) <br />Your Signatury' <br />Joyce J Gay <br />Your Name Printed <br />Your Address <br />3(\ , - 5-`I <br />Your Phone Number <br />NOTARY <br />State of Nebraska <br />[County] of -ltki :l <br />Date <br />)s <br />) <br />This document was acknowledged before me on <br />by <br />1LA <br />Name of PJncipai <br />ignature of Notary <br />My commission expires: 1.1! <br />Power of Attorney, DC 6:12 PSC, Rev. 08/12 §30-4041 <br />Date <br />MLTC-PB-3 (99009) 2/21 <br />