Nebraska Power Of Attorney For Health Care Form Page 3

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Declaration of Witnesses
We declare that the principal is personally known to us, that the principal signed or
acknowledged his or her signature on this power of attorney for health care in our
presence, and that the principal appears to be of sound mind and not under duress or undue
influence, and that neither of us nor the principal’s attending physician is the person
appointed as attorney in fact by this document.
Witnessed By:
_______________________________
_______________________________
(Signature of Witness/Date)
(Printed Name of Witness)
_______________________________
_______________________________
(Signature of Witness/Date)
(Printed Name of Witness)
OR
State of Nebraska
)
) ss,
County of ___________________________
)
On this _____ day of ______________________ 20 __, before me, ______________
_________________________, a notary public in and for __________________________
County, personally came _______________________________, personally known to be
the identical person whose name is affixed to the above power of attorney for health care
as principal, and I declare that he or she acknowledges the execution of the same to be his
or her voluntary act and deed, and that I am not the attorney-in-fact or successor attorney-
in-fact designated by this power of attorney for health care.
Witness my hand and notarial seal at _______________________ in such county the
day and year last above written.
_______________________________
Notary Public

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