Georgia Advanced Directive Page 22
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29Name: ___________________________________________________________
Address: __________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers: ________________________________________________
_________________________________________________________________
(Home, Work, and Mobile/Cell)
E-Mail Address: ____________________________________________________
I wish for my body to be:
__________ (Initials) Buried
OR
__________ (Initials) Cremated
PART TWO: TREATMENT PREFERENCES
[PART TWO will be effective only if you are unable to communicate your
treatment preferences after reasonable and appropriate efforts have been
made to communicate with you about your treatment preferences. PART
TWO will be effective even if PART ONE is not completed. If you have not
selected a health care agent in PART ONE, or if your health care agent is
not available, then PART TWO will provide your physician and other health
care providers with your treatment preferences. If you have selected a
health care agent in PART ONE, then your health care agent will have the
authority to make all health care decisions for you regarding matters
covered by PART TWO. Your health care agent will be guided by your
treatment preferences and other factors described in Section (4) of PART
ONE.]
Page 8 of 15
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