Form Rev 133c7e0 - Pa Power Of Attorney For My Health Care - Medical Power Of Attorney

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Commonwealth of Pennsylvania
Rev. 133C7E0
POWER OF ATTORNEY FOR MY HEALTH CARE
A Simple Health Care Advance Directive
This form combines the many different state legal requirements into a “universal” legal form that is
intended to meet the basic requirements in most states. This form has space so you can add any special
instructions or limitations you wish to include. But remember, this form is a basic Health Care Power of
Attorney. It is not meant for a lengthy statement of your wishes and preferences. Remember, you should
discuss your wishes and priorities directly with your agent and with others who are close to you.
INFORMATION ABOUT THE PRINCIPAL
Michelle R Kane
Principal’s Full Name
2887 Coal Road
Principal’s Street Address
Scranton
PA
18503
City
State
Zip Code
(570) 589-1149
(570) 445-6542
Principal’s Daytime Phone
Principal’s Other Phone
August 04, 1980
Principal’s Birthday
Principal’s Email Address
WHO WILL BE YOUR HEALTH CARE AGENT?
William S Bryan
Agent’s Full Name
4099 Pick Street
Agent’s Street Address
Loveland
CO
80537
City
State
Zip Code
(970) 619-2564
(970) 308-2670
Agent’s Daytime Phone
Agent’s Other Phone
Agent’s Email Address
Medical Power of Attorney (Rev. 133C7E0)
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