Georgia Durable Power Of Attorney Will To Live Form (Page 4 of 5) in pdf

Georgia Durable Power Of Attorney Will To Live Form Page 4

be born alive. I also direct that lifesaving procedures be used even if I am legally determined to

be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I

specify by writing my signature in the box below, no one is authorized to consent to any

procedure for me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above,

medical procedures required to prevent my death are authorized even if they may result in the

death of my unborn child provided every possible effort is made to preserve both my life and the

life of my unborn child.

____________________________________

Signature of Declarant

This power of attorney shall be effective in the event I become disabled, incapacitated or

incompetent. I am fully informed about all the contents of this form and understand the full

import of this grant of powers to my agent.

Signed________________________________________________________________________

(Signature of principal)

Date__________________________________________________________________________

The principal has had an opportunity to read the above form and has signed the above form in our

presence. We, the undersigned, each being over 18 years of age, witness the principal’s signature

at the request and in the presence of the principal, and in the presence of each other, on the day

and year above set out.

Witnesses:

Addresses:

______________________________________

____________________________________

______________________________________

____________________________________

Additional witness is required when health care agency is signed in a hospital or skilled

nursing facility:

I hereby witness this health care agency and attest that I believe the principal to be of sound mind

and to have made this health care agency willingly and voluntarily.

Witness:__________________________________________________

(Attending physician)

Address:______________________________________________________________________

Page 4 of 5

Georgia Durable Power Of Attorney Will To Live Form Page 4