Witnesses: I attest that the Declarant signed or acknowledged this Living Will Declaration in my
presence and that the Declarant appears to be of sound mind and not under or subject to
duress, fraud or undue influence. I further attest that I am not an agent designated in the
Declarant’s Health Care Power of Attorney, I am not the attending physician or the Declarant, I
am not the administrator of a nursing home in which the Declarant is receiving care, and I am an
adult not related to the Declarant by blood, marriage or adoption.
Signature: ___________________________________________ Date: ____________
Address: ______________________________________________________________
Signature: _____________________________________________ Date:____________
Address: _______________________________________________________________
OR
Notary Acknowledgment.
State of Ohio
County of ___________________, ss
On ___________________________, _____________, before me, the undersigned
(date)
(year)
Notary Public, personally appeared _______________________________________
(Declarant)
known to me or satisfactorily proven to be the person whose name is subscribed to the above
Living Will Declaration as the Declarant, and who has acknowledged that (s)he executed the
same for the purposes expressed therein. I attest that the Declarant appears to be of sound
mind and not under or subject to duress, fraud or undue influence.
_______________________________________________
Notary Public
My Commission Expires: __________________________