Durable Power Of Attorney For Health Care Choices & Health Care Choices Directive Page 6
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DURABLE POWER OF ATTORNEy FOR HEALTH CARE & HEALTH CARE DIRECTIVE
Sign this form before two witnesses who are not related to you or financially connected to your estate.
______ ____, ________.
IN WITNESS THEREOF, I have executed this document on __________
MONTH
DAY
YEAR
__________________________________________________________________________
Signature ___
_____________________________________________
________________________
Print name
SS No.
______________________________________________________________________________
Address
The person who signed this document is of sound mind and voluntarily signed this document
in our presence. Each of the undersigned witnesses is at least 18 years of age.
________________________________
___________________________________
Signature
Signature
_______________________________
_________________________________
Print name
Print name
___________________
__________
_________________________________
__
Address
Address
___________________________________ _____________________________________
Notarization required
STATE OF MISSOURI
)
) SS
COUNTY OF _____________________ )
On this ____ day of ____________________, in the year of ________, personally appeared
before me the person signing, known by me to be the person who completed this document
and acknowledged it as his/her free act and deed.
IN WITNESS WHEREOF, I have set my hand and affixed my official seal in the County of
________________________, State of Missouri, the day and year first above written.
_______________________________________
Notary public’s signature
20
LIFE CHOICES
ago.mo.gov
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