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,. <br />•~ <br />2QOOO~ssS <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. Y <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 />Ll-I,A ~?. 130L`I`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 trhis 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 />Witnessed by: <br />r ~'~' Cry <br />Si to e b Witness <br />Sign ure d Wi Hess <br />Date Prints Name of Witness <br />(.J~ ~ . <br />Date Pri ted Name of W mess <br />STATE OF' NEBRASKA ) <br />ss. <br />COUNTY OF HALL ) <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 />IN WITNESS WHEREOF, T have hereunto subscri$~T my name and <br />affixed my official seal the da~,y---aid year las , eve written. <br />GENERAL NOTARY -State of Neb aY, ,'p ~ 1 c <br />JOHN M. CUNNWGH Y,~ <br />My Camm. Exp. Nov. 22, 2007 <br />,` <br />-5- <br />