Durable Health Care Power Of Attorney Questionnaire Template (Page 3 of 3) in pdf

Funeral and Burial Disposition (Optional. Your agent will have the authority to carry out all matters relating to your

funeral and burial disposition wishes in accordance with this power of attorney, which is effective upon your

death. You may state your wishes in the power of attorney.):

My wishes are reflected below:

________

Upon my death, I direct my body to be buried (as opposed to cremated).

________

Upon my death, I direct my body to be buried in:

______________________________________________________________________

________

Upon my death, I direct my body to be cremated.

________

Upon my death, I direct my body to be cremated with my ashes to be:

______________________________________________________________________

________

My agent will make all funeral and burial disposition decisions.

After your Durable Health Care Power of Attorney is prepared, please review it prior to signing to ensure it is consistent

with your wishes. If it is not, contact me and we can correct any inaccuracies. Do not sign your Durable Health Care

Power of Attorney until your witness or a Notary Public is present to watch you sign it. The witness must be at least 18

years of age, cannot be family (related by blood, adoption, or marriage), cannot be in your will to receive part of your

estate, cannot be appointed as your representative, and cannot be a health care giver. A witness can be a neighbor,

friend, or an acquaintance who is an adult, is not in your will, and is not caring for you or representing you. Then, it is

critical that you talk about the documents and your wishes with your family, your agent, and your physician. An agent

needs to know what your feelings are in order to act on your behalf. You also need to make sure that the appropriate

people have copies of the documents, including your agent, your family, and your physician. You may also register a

copy of your documents with the Secretary of State. For more information, please contact me or visit the Secretary of

State’s website at If you have a Living Will and a Durable Health Care Power of Attorney, you

must attach the Living Will to the Durable Health Care Power of Attorney.

Additional specific requests or instructions for me:

***Please indicate if you are interested in obtaining more information on any of the following additional forms:

________

Living Will

________

Durable Mental Health Care Power of Attorney

________

General (Financial) Power of Attorney

________

Other Legal Information/Representation: __________________________________________________

Durable Health Care Power Of Attorney Questionnaire Template Page 3