Vermont Advance Directive For Health Care (Page 2 of 8) in pdf

Vermont Advance Directive For Health Care Page 2

Part Th ree of this form lets you express your wishes about organ or tissue donation.

Part Four is for you to express your wishes about

Part Four

funeral arrangements or other provisions

for your remains after you die.

Part Five of this form is for

Part Five

signatures. You must sign and date the form in the presence of

two adult witnesses. Th e following persons may not be witnesses: your agent(s), your spouse or

not be witnesses: your agent(s), your spouse or

not

partner, reciprocal beneﬁ ciary, siblings, parents, children, or grand children.

You should give copies of the completed form to your agent and alternate agents, to your

copies of the completed form to your agent and alternate agents, to your

copies

physician, to your family, and to any health care facility you reside or at which you are likely

to receive care. You should keep a list of those who have copies in case you revoke or revise the

document in the future.

You have the right to revoke or suspend all or part of this Advance Directive for health care or

replace this form at any time. If you do revoke it, all old copies should be destroyed.

You may wish to read the booklet Taking Steps to help you think about and discuss diﬀ erent

choices and situations with your agent or loved ones.

Vermont Advance Directive For Health Care Page 2