Maine Power Of Attorney For Health Care Will To Live Form (Page 4 of 4) in pdf

Maine Power Of Attorney For Health Care Will To Live Form Page 4

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

Signed this ____________________day of ___________________________, 20_______.

Signature______________________________________________________________________

Address

Date of Birth or Social Security Number

The principal voluntarily signed this writing in my presence.

First Witness Signature:__________________________________________________________

Residence Address:______________________________________________________________

Second Witness Signature:________________________________________________________

Residence Address:______________________________________________________________

form prepared 2001

*clerical changes made 11/05

Page 4 of 4

Maine Power Of Attorney For Health Care Will To Live Form Page 4