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Surrogate Decision Making in Nebraska <br />Nebraska gaie niton Agg <br />SIGNATURE AND ACKNOWLEDGMENT <br />(CAUTION: This document MUST be signed IN THE PRESENCE of a notary to comply with the Nebraska <br />Uniform Power of Attorney Act) <br />VC. " t fle cis /`•€-- 9e - 3 <br />Your Signature Date <br />tfbyl<a cle,,O5hrIA,1 e4n <br />Your Name Printed <br />tpi ;i - C *. to lime (p <br />Your Address <br />Your Phone Numbdr <br />11'71... <br />NOTARY <br />State of Nebraska <br />[County] of \,\ <br />) ss. <br />This document was acknowledged before me on <br />by Qan-iP.Vwleu", <br />Name of Principal <br />%pt6 c--0.)tt, <br />Signature of Notary <br />My commission expires: <br />531000.471 <br />Power of Attorney, DC 6:12 PSC, Rev. 08/12 §30-4041 <br />Date <br />(Seal, if any) <br />MLTC-PB-3 (99009) 2/21 <br />