Missouri Living Will Page 2
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2Missouri Durable Power of Attorney for Healthcare
I, _______________________________________________________________________
(name of principal)
________________________________________________________________________
(address)
hereby designate __________________________________________________________
(name of attorney in fact)
________________________________________________________________________
(address)
__________________________________
____________________________________
(home telephone number)
(work telephone number)
as my attorney in fact.
In the event the person I designate above is unable, unwilling or unavailable to act as my attorney in fact, I hereby appoint
________________________________________________________________________
(name of alternate attorney in fact)
________________________________________________________________________
(address)
__________________________________
____________________________________
(home telephone number)
(work telephone number)
THIS IS A DURABLE POWER OF ATTORNEY AND THE AUTHORITY OF
MY ATTORNEY IN FACT S HALL NOT TERMINATE IF I BECOME DISABLED OR INCAPACITATED.
This power of attorney becomes effective upon certification by two licensed physicians that I am incapacitated and can no
longer make my own medical decisions. The powers and duties of my attorney in fact shall cease upon certification that I am no longer
incapacitated. This determination of incapacity shall be periodically reviewed by my attending physician and my attorney in fact.
I authorize my attorney in fact and successor attorney in fact to make any and all healthcare decisions for me, including
decisions to withhold or withdraw any form of life support. I expressly authorize my attorney in fact (and alternate attorney in fact)
to make all decisions regarding the provision, the withholding or the withdrawing of artificially supplied nutrition and hydration in all
medical circumstances.
I, ____________________________________________, the principal, sign my name to this instrument this ______ day
of _________________________20 _____ and being first duly sworn, do hereby declare to the undersigned authority that I sign it
willingly, that I execute it as my free and voluntary act for the purposes there in expressed, and that I am eighteen years of age or
older, of sound mind, and under no constraint or undue influence.
________________________________________________________________________
(principal)
The State of Missouri
The County of ____________________________________________________________
Subscribed, sworn to, and acknowledged before me by ______________________________________________, the
principal, this _____ day of _______________________, 20 _____.
(seal)
________________________________________
(notary public)
AN ORGANIZATION OF
AMERICANS FOR LEGAL REFORM
Email:
Phone: 1-888-FOR-HALT (202) 887-8255
1612 K Street, NW Suite 510, Washington, DC 20006
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