Vermont Statutory Form With Will To Live Language Page 5
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5Statement of ombudsman, a recognized member of the clergy, and attorney licensed to
practice in the state, or a probate court designee (to be signed only if the principal is in or is
being admitted to a hospital, nursing home or residential care home):
I declare that I have personally explained the nature and effect of this Advance Directive to the
principal and that the principal understands the same.
_________________________________________
______________________________
(signature)
(date)
(print name)
(address)
Form prepared 2005
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