Vermont Advance Directive For Health Care Page 8
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8ADVANCE DIRECTIVE, PAGE 6
_____ MD
_________________________________________________________________________
NAME
____________________________________________________________________________
ADDRESS
_____ Hospital(s)
_____________________________________________________________________
NAME
___________________________________________________________________________________
___________________________________________________________________________________
_____ Other individuals or locations: (use additional sheet if needed)
___________________________
NAME
ADDRESS _________________________________________________
_______________________________
_______________________________________________
_______________________________
_______________________________________________
_______________________________
_______________________________________________
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