Ohio Durable Power Of Attorney For Health Care Will To Live Form (Page 6 of 7) in pdf

Ohio Durable Power Of Attorney For Health Care Will To Live Form Page 6

SEVERABILITY

Any invalid or unenforceable power, authority, or provision of this instrument shall not affect

any other power, authority, or provision or the appointment of my attorney in fact to make health

care decisions.

PRIOR DESIGNATIONS REVOKED

I hereby revoke any prior Durable Power of Attorney for Health Care executed by me.

I understand the purpose and effect of this document and sign my name to this Durable Power of

Attorney for Health Care after careful deliberation.

(Signature of Principal)___________________________________________________________

(Date)________________________________________________________________________

THIS DURABLE POWER OF ATTORNEY FOR HEALTH CARE WILL NOT BE VALID

UNLESS IT IS EITHER (1) SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED

BELOW WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR

SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC

WITNESSES SIGNATURE

I attest that the principal signed or acknowledged this Durable Power of Attorney for Health Care

in my presence, that the principal appears to be of sound mind and not under or subject to duress,

fraud, or undue influence. I further attest that I am not the attorney in fact designated in this

document, I am not the attending physician of the principal, I am not the administrator of a

nursing home in which the principal is receiving care, and that I am an adult not related to the

principal by blood, marriage, or adoption.

First Witness Signature:__________________________________________________________

Print Name:____________________________________________________________________

Date:_________________________________________________________________________

Residence Address:______________________________________________________________

______________________________________________________________________________

Second Witness Signature:________________________________________________________

Print Name:____________________________________________________________________

Date:_________________________________________________________________________

Residence Address:______________________________________________________________

______________________________________________________________________________

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Ohio Durable Power Of Attorney For Health Care Will To Live Form Page 6