Laserfiche WebLink
201007984 <br />DECISIONS FOR ME IF I AM INCAPASLE OF MAKING SUCH DECISIONS. I <br />ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR <br />HEALTH CARE AT ANY T�ME BY NOTTFYING MY ATTORNEY IN FACT, MY <br />PHYSICIAN, OR THE FAC�LITY IN WHICH I AM A PATIENT OR RES2DENT. I <br />ALSO UNDERSTAND THAT I CAN REQU�RE IN THIS POWER OF ATTORNEY FOR <br />HEALTH CARE THAT THE FACT OF MY INCAPACITY TN THE FUTURE SE <br />CONF�RMED BY A SECOND PHYSICIAN. <br />� •� <br />DELORES J. BRUN , Principal <br />DECLARAT�ON OF WITNES$ES <br />we declare that the princ�pal is personally known to us, that <br />the pri,r�cipal signed or acknowledged her signature on this Durable <br />General and Health Care Power af Attorney in our presence, �hat <br />the principal appears td be of sound mind and not under duress or <br />undue influence, and that neither of us nor the principal's <br />attenda.ng physician is th� pe�son appointed as At�orney in F'act by <br />�his document. <br />Witnessed by: <br />� . ,� ,_ �--��1�- <br />gnature of Wa.tn s <br />COUNTY OF HALL <br />�x� <br />a�/��/�� <br />Date <br />c -� �� <br />�ate <br />`� � < « a 5 .� �. � ., � �.. <br />Printed Name of Witn�ss <br />`�F7he� � C�chi l G���� <br /><� <br />�rint d Name o� Witness <br />DELORES J. BRUNS, b�ing th� named pr.a.ncipal, who is to me <br />known. to be the person. described in and wh� executed th� above <br />Durable General and Health Ca�e Power of Attorney, acknowJ�edges <br />th� same to be her voluntary act and d�ed. <br />-5- <br />