Vermont Advance Directive For Health Care Page 7
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8ADVANCE DIRECTIVE, PAGE 5
NAME _________________________________________________________________________ DOB ______________________ DATE __________________
I want a Funeral Ceremony with a burial or cremation to follow
I prefer only a Graveside Ceremony
I prefer only a Memorial Ceremony with burial or cremation preceding
Other Details: (such as music, readings, Officiant)
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Eclaration of
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You must sign this before TwO adult witnesses. The following people may not sign as witnesses:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
your agent(s), spouse, reciprocal beneficiary, parents, siblings, children or grandchildren.
I declare that this document reflects my health care wishes and that I am signing this Advance
Directive of my own free will.
SIGNED ____________________________________________________________________________________________ DATE ___________________________________
I affirm that the signer appeared to understand the nature of this advance directive and to be free from
duress or undue influence at the time this was signed. (Please sign and print)
FIRST wITNESS (PRINT NAME) ___________________________________________________________________________________________________________________
SIGNATuRE ________________________________________________________________________________________ DATE _____________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
SECOND wITNESS (PRINT NAME) ________________________________________________________________________________________________________________
SIGNATuRE ________________________________________________________________________________________ DATE _____________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
If the person signing this document is a current patient or resident in a hospital, nursing home or
residential care home, an additional person (designated hospital explainer, long-term care ombudsman,
member of the clergy, Vermont attorney, or person designated by the probate court) needs to confirm
below that he or she has explained the nature and effect of the Advance Directive and that the patient or
resident appears to understand this.
NAME _____________________________________________________________________________________________ DATE ____________________________________
TITLE / POSITION ___________________________________________________________________________________ PHONE ___________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
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