Advance Directive For Health Care (Page 7 of 7) in pdf

Advance Directive For Health Care Page 7

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

ADVANCE DIRECTIVE FOR HEALTH CARE

CDCR 7421 (REV. 09/09)

Notary – Not required if two witnesses have signed document

In unusual circumstances, such as two witnesses are not available, a notary may be used to verify the

patient-inmate’s signature on this document.

Notary Public – State of California

County of _________________________________

On __________________________ before me, _________________________________________

(Insert Name of Notary Public)

personally appeared _______________________________________________________________,

(Insert the Name of Principal)

Personally known to me (or proved to me on the basis of satisfactory evidence) to be the person

whose name is subscribed to the within instrument and acknowledged that he/she executed the same

in his/her authorized capacity and that by his/her signature on the instrument the person upon behalf

of which the person acted, executed the instrument.

WITNESS my hand and official seal.

NOTARY SEAL ___________________________________

(Signature of Notary)

Statement of Patient Advocate or Ombudsman

If the patient-inmate is currently residing in a Skilled Nursing Facility, the following must be

completed by a patient advocate or ombudsman (This does not apply to OHU, CTC, Hospice, or

GACH).

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 witness as

required by Section 4675 of the Probate Code.

(Date)

(Signature)

(Address)

(Printed Name)

Distribution: Original-UHR, Copy to Inmate

Page 7 of 7

Advance Directive For Health Care Page 7