Combined Living Will And Health Care Power Of Attorney (Page 5 of 5) in pdf

SECOND ALTERNATE HEALTH CARE AGENT

________________________________________________________________________________________________

NAME / RELATIONSHIP

__________________________________________________________________________________________________

ADDRESS

TELEPHONE NUMBER:

Home

___________________________________

Work

___________________________________

Cell

___________________________________

E-MAIL ______________________________________________________________________________________

Having carefully read this document, I sign it this _______ day of ___________________________, 20_____,

revoking all previous health care powers of attorney and health care treatment instructions.

___________________________________________________

Sign full name here

WITNESS: __________________________________________

Two witnesses at least 18 years of age are required by Pennsylvania law. If someone signs this document at

your direction and on your behalf, that person may not be a witness too. To limit questions which might

arise, the witnesses should not be anyone who will inherit property from you, be creditors or be employed by

any of your health care providers.

NOTARIZATION (OPTIONAL)

This form does not need to be notarized under Pennsylvania law, but if it is witnessed and notarized, it is

more likely to be accepted under the laws of some other states.

On this _______ day of ___________________________, 20_____, before me personally appeared the aforesaid

declarant and principal to me known to be the person described in and who executed the foregoing document

and acknowledged that he/she signed the document as his/her free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in

___________________________ County, State of ___________________, the day and year first above written.

___________________________________________________

NOTARY PUBLIC

My Commission expires ________________

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Combined Living Will And Health Care Power Of Attorney Page 5