Fillable Statutory Advance Directive (Page 6 of 8) in pdf

which I currently reside or have applied for admission – unless related to me by

blood, marriage or adoption. The person I have chosen to act as my agent and to

whom I give full authority to make all medical and health care decisions for me at

any time during which I am unable to make them for myself, is:

21.

Name of Agent: __________________________________________________

Address: ________________________________________________________

Telephone: Home:_____________________ Work:______________________

Cell Phone or Pager: ___________________ E-mail: ____________________

22. If for any reason I revoke the authority of my agent, or this individual is unavailable,

unwilling, or otherwise ineligible to make decisions for me, the following individuals (to

act alone and successively, in order of priority as listed) are authorized to serve as

alternate proxies:

23.

Name of Alternate #1:_____________________________________________

Address: ________________________________________________________

Telephone: Home:_____________________ Work:______________________

Cell Phone or Pager: ___________________ E-mail: ____________________

24.

Name of Alternate #2: ____________________________________________

Address: ________________________________________________________

Telephone: Home:_____________________ Work:______________________

Cell Phone or Pager: ___________________ E-mail: ____________________

25. Each alternate successor designated shall be vested with the same power and duties as if

originally named as my health care agent. These persons, in priority of the order

presented, are to have binding authority over any and all other persons to make my

personal and health care decisions. In making decisions in my behalf if my wishes are not

clear, I direct my agent to act in his/her best understanding of what my wishes would

have been. And, where not reasonably sure of what I would have wanted, to act

according to his/her belief in my interests as determined from his/her knowledge of my

personal and family affairs, and other goals and values in life. The authority of my agent

shall not be terminated unless it appears that he or she is clearly and obviously not acting

in accordance with my known wishes, or is overwhelmingly ignoring my best interests if

my wishes are not otherwise known.

SPECIFIC AGENT AUTHORITY AND GENERAL INTENT:

26.

My agent shall have the same authority to make health care decisions for me as I would if

I had the capacity to make them myself, subject to any limitations imposed through this

document. Below are listed further specific authorities given to my agent as named in this

document:

Statutory Advance Directive Page 6