New Jersey Durable Power Of Attorney For Health Care Will To Live Form (Page 5 of 5) in pdf

New Jersey Durable Power Of Attorney For Health Care Will To Live Form Page 5

–– WITNESSES —

I declare that the person who signed this document, or asked another to sign this document on

his or her behalf, did so in my presence, that he or she is personally known to me, and that he or

she is of sound mind and free of duress or undue influence. I am 18 years of age or older, and

am not named by this document as the person’s health car representative nor as a successor

health care representative.

First Witness Signature:__________________________________________________________

Residence Address:______________________________________________________________

Date:_________________________________________________________________________

Second Witness Signature:________________________________________________________

Residence Address:______________________________________________________________

Date:_________________________________________________________________________

-ALTERNATIVE TO WITNESSES-

ACKNOWLEDGMENT BY NOTARY PUBLIC, ATTORNEY AT LAW, OR OTHER

PERSON AUTHORIZED TO ADMINISTER OATHS.

On ___________________________, before me came _________________________________,

(date)

(name of declarant)

whom I know to be such person, and the declarant did then and there execute this declaration.

Sworn to before me this ________________ day of __________________, _______.

_________________________________

Notary Public, Attorney at Law

Other Person Authorized to Administer Oaths

Form Prepared 2005

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New Jersey Durable Power Of Attorney For Health Care Will To Live Form Page 5