Health Care Power Of Attorney (Page 3 of 4) in pdf

Health Care Power Of Attorney Page 3

by blood, adoption or marriage, and not entitled to any part of his/her estate. I am at least

19 years old and am not directly responsible for his/her medical care or expenses.

_________________________

Signature of Witness

_________________________

Name of Witness

Date: _____________

and

________________________

Signature of Witness

_________________________

Name of Witness

Date: _____________

ATTESTATION

I, the undersigned authority in and for said County in said State, hereby certify that

__________________, whose name is signed to the foregoing Durable Health Care

Power of Attorney, and who is known to me, acknowledged before me on this day that,

being informed of the contents of the said document, (s)he executed the same voluntarily,

before the witnesses whose names appear above, on the day the same bears date.

Given under my hand this _________ day of _____________, 2002.

__________________________

Notary Public

My commission expires:

_____________________

SIGNATURES OF AGENTS

I, ____________________, am willing to serve as Health Care Agent.

Signature: ______________________ Date: ______________

I, _____________________, am willing to serve as Health Care Agent if the first-named

Agent cannot serve.

Health Care Power Of Attorney Page 3