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.~ . <br />. '` ~241~0~GG7 <br />DECLARATION OF WITNESSES <br />We declare that the principal is personally known to us, that the <br />principal signed or acknowledged her signature on this Durable General and <br />Health Care Power of Attorney in our presence, that the principal appears to <br />be of sound mind and not under duress or undue influence, and that neither <br />of us nor the principal's attending physician is the person appointed as <br />Attorney in Fact by this document. <br />Witnessed by: <br />._____~- <br />Signature of Witne s <br />S gnature of Witness <br />Date Printed Name of Witness <br />~~~ G <br />Date Printed Name Witness <br />STATE OF NEBRASKA ) <br />ss: <br />COUNTY OF HALL ) <br />Geraldine Barrientos, being the named principal, who is to me known <br />to be the person described in and who executed the above Durable General <br />and Health Care Power of Attorney, acknowledges the same to be her <br />voluntary act and deed. <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and <br />affixed my official seal the day and year last above written. <br />GENERAI. NOTaP.Y•Sirte al MebiasMa ~~ ~~~ <br />_, ~~~ ST^~_P6icM J. DU 1G s Not ry Pu lc <br />