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202506490 <br />Surrogate Decision Making in Nebraska Nebraska State Unit on Aging <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 />Your Signature Date <br />1.4n0k ie / 11a'cJ <br />Your Name Printed <br />17/N Eold <br />Your Address <br />.og- v. 7S-9 <br />Your Phone Number <br />NOTARY <br />State of Nebraska <br />(County] of a— _ <br />) ss. <br />This document was acknowledged before me on <br />by 1-1\11-61-bc- I}/Lark. <br />Name of Principal <br />Signature of Notary <br />My commission expires: I 1 j / 0i Oa9l <br />Power of Attorney, DC 6:12 PSC, Rev. 08/12 §30-4041 <br />Date <br />(Seal, if any) <br />GENERAL NOTARY • Sta►e of Nebraska <br />HEATHER L. FURSTENAU <br />My Come Ev. May 10, 2026 <br />POLLARD, LINDA K <br />DOB: 9/1211948 (76 yrs) Female <br />MRN: 801533066 Adm Date: 7/24/2025 <br />CSN: 400335326641 Unit: SFMC4PCU <br />I I1I11111111II111111111N <br />MLTC-P8-3 (99009) 2/21 <br />