State Of West Virginia Living Will (Page 2 of 2) in pdf

State Of West Virginia Living Will Page 2

I did not sign the principal’s signature above for or at the direction of the principal. I am at least eighteen

years of age and am not related to the principal by blood or marriage, entitled to any portion of the estate

of the principal to the best of my knowledge under any will of principal or codicil thereto, or directly

financially responsible for principal’s medical care. I am not the principal’s attending physician or the

principal’s medical power of attorney representative or successor medical power of attorney

representative under a medical power of attorney.

Witness

DATE

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

State Of West Virginia Living Will Page 2