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, D <br />'' 201��927 <br />�� <br />IN WITNESS WHEREOF, I have executed this document this ✓ <br />day of September, 2006, at Grand Island, Hall County, Nebraska. <br />I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I <br />UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE �I�TD DEATH <br />DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I <br />ALSO UNDERST�ND 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 PHYSICI <br />. <br />� <br />CARLIT J. CHEL, Principal <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 this Durable <br />General and Health Care Power of Attorney in our presence, that <br />tlie principal appears to be of sound mind and not under duress or. <br />undue influence, and that neither of us nor the principal's <br />attending physician is the person ap� as Attorney in Fact by <br />tYiis document . <br />Witnessed by: <br />� <br />. � <br />�� <br />�_,• (�'��r� �� �r���.e � ,,; , ;-�-�;�.a c'k!y Sheryl Schilowsky <br />Signa 5 re of Witness��`�' Date Printed Name ot Witness <br />r� �� r � a( ' <br />;, , ° ( ,1 - Stephanie L. Ounsombath <br />Sign , ure of Witness Date Printed Name of Witness <br />STATE OF NEBt ) <br />) ss. <br />COUIJTY OF HALL } <br />CARLITA J. MICHEL, being the named principal, who is to me <br />known to be the person described in and who executed the above <br />vurable General and Health Care Power of Attorney, acknowledges <br />the same to be her voluntary act and deed. <br />-5- <br />