Catholic Declaration On Life And Death (Page 3 of 3) in pdf

Catholic Declaration On Life And Death Page 3

person appointed as agent by this advance directive, and (5) that I am not the individual’s health care

provider, an employee of the individual's health care provider, the operator of a community care

facility, an employee of an operator of a community care facility, the operator of a residential care

facility for the elderly, nor an employee of an operator of a residential care facility for the elderly.

FIRST WITNESS

Name:

Telephone:

Address:

Signature of Witness

Date:

SECOND WITNESS

Name:

Telephone:

Address:

Signature of Witness

Date:

ADDITIONAL STATEMENT OF WITNESS: At least one of the above witnesses must also sign

the following declaration:

I further declare under penalty of perjury under the laws of California that I am not related to the

individual executing this advance health care directive by blood, marriage, or adoption, and to the

best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death

under a will now existing or by operation of law.

Signature of Witness:

If you are a patient in a skilled nursing facility, the patient advocate or ombudsman must sign the

following statement:

STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN

I declare under penalty of perjury under the laws of California that I am a patient advocate or

ombudsman as designated by the State Department of Aging and that I am serving as a witness as

required by Section 4675 of the Probate Code.

Date:

Name:

(sign your name)

(print your name)

Address:

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Catholic Declaration On Life And Death Page 3