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<br /> substantial toss of cons+�uusness and cepac�ty for cog�itive iatersciion aritb the :t..:'` ��.
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<br />�,<��., �:��, I HAV� RE� THIS POWER OF ATTORNEY FOR AEALTH CARE. I ..��� ,=�=
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<br /> ..`�� UNDERSTAND THAT �T ALLOWS ANOTHER PFdtSON TO MARE L�FE AND . ,•, r _•"?'
<br /> � `� DEATH DECLSIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH .
<br /> �`�°' •, . ." � `�"��.=; DECISIQNS. I ALSO UNDERSTAiVD THAT I CAN REVOKE T�S pO�GVVER OF �:',:;':,: :�
<br /> �$:�• ,� ��. '- `' AT�'ORNEY F�R HEALTH CARE AT ANY TIl1� BY NOri'IFYINt3 N1Y -
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<br /> R+� , , : , ` . ` A'I°fORNEY IN FAGT, MY P�iYSICIAN, OR Ti�FACaI.ITY IN WI�CH I AM A —
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<br /> ='�= � �� � � '`�� � PATIENT OR RESIDENT. I ALSO iJ1�IDE�STAND THAT I CAl� REQUIRE lN
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<br /> - ---------:--:s-=•, THIS POWER �F A'ITORNEY FOR HEALTH CARE THAT TH� f�ACT OF MY . _ _�
<br />�,�.j.� .�:;.� �' .� "�;`a.� INCAPACITY IN Tf�FUT�JItE BE CONFIRNI�D BY A SECOND PHYSICIAN. _ :. .':`�r-�-_=:
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<br /> ,�� ,? ,'i ': VUe derlare that t�p�iaapai is personallg�own w u�tbai the gsincipal siSued ur �* :—.
<br /> �.:,.;e,�:. : ``. ; . a c l m o w l e d g e d her s�g m t u re oa this power of attomey for heatt�care in aw preseac�that ='_ `___
<br />�. � . ' ..;':;,,_ the pr�aapai appears to be of sound mind and not under duress or undue i�uenc� an d ..:� �,��
<br /> - ° �, „';;`� th$t r�it�er of us nor the priacipaPs atte�ding phyaician is the person appointed as atto�tey .. `a,� _-
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<br /> . in fact by t�is document. • , --
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<br />-� � . . STATE OF NEBRASKA ) � .
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<br /> °;':� . .. . COUNTY OF } , .
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<br /> �-�.•�:" � On this,�dey of �• , 1997,before me��u�
<br /> • a notary pubtic in and for �t Coumy,personaUy came ' Stearley,personaUy to
<br />`_.: . me kaown to be the identical person whose name is a�xed to the above durable power of . � .. .
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