Fillable Combined Medical Power Of Attorney And Living Will (Page 3 of 3) in pdf

Combined Medical Power Of Attorney And Living Will Page 3

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2. Other directives:

THIS MEDICAL POWER OF ATTORNEY SHALL BECOME EFFECTIVE ONLY

UPON MY INCAPACITY TO GIVE, WITHHOLD OR WITHDRAW INFORMED

CONSENT TO MY OWN MEDICAL CARE.

_______________________________________ DATE _________________

Signature of the Principal

I did not sign the principal's signature above. I am at least eighteen years of age and am

not related to the principal by blood or marriage. I am not entitled to any portion of the

estate of the principal or to the best of my knowledge under any will of the principal or

codicil thereto, or legally responsible for the costs of the principal's medical or other care.

I am not the principal's attending physician, nor am I the representative or successor

representative of the principal.

Witness _______________________________ DATE _________________

STATE OF ___________________________________

COUNTY OF _________________________________

I, ______________________, a Notary Public of said County, do certify

that_____________________, as principal, and ____________________ and

____________________, as witnesses, whose names are signed to the writing above

bearing date on the _____ day of ______________, 20___,

have this day acknowledged the same before me.

Given under my hand this _______ day of ___________________, 20___.

My commission expires:_______________________________

______________________________________

Signature of Notary Public

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Combined Medical Power Of Attorney And Living Will Page 3

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