New Hampshire Durable Power Of Attorney For Health Care Page 3
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3Signed this __________ day of __________________, 20_____
Principal's Signature: ____________________
[If you are physically unable to sign, this directive may be signed by someone else
writing your name, in your presence and at your express direction.]
THIS POWER OF ATTORNEY DIRECTIVE MUST BE SIGNED BY TWO
WITNESSES OR A NOTARY PUBLIC OR A JUSTICE OF THE PEACE.
We declare that the principal appears to be of sound mind and free from duress at the
time the durable power of attorney for health care is signed and that the principal
affirms that he or she is aware of the nature of the directive and is signing it freely and
voluntarily.
Witness Signature: _______________ Address: ____________________
Witness Signature: _______________ Address: ____________________
STATE OF NEW HAMPSHIRE
COUNTY OF ____________________
The foregoing durable power of attorney for health care was acknowledged before me
this ___ day of _____________, 20____, by _______________ ("the Principal'').
____________________
Notary Public/Justice of the Peace
My commission expires:_______________
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