Illness And Hospitalization Living Will Form (Page 2 of 2) in pdf

Illness And Hospitalization Living Will Form Page 2

Illness and Hospitalization

Living Will Form

Witness Statements

I declare that the person who signed or acknowledged this document is personally known to me,

that he/she signed or acknowledged this Living Will Declaration in my presence, and that he/she

appears to be of sound mind and under no duress, fraud, or undue influence.

_______________________________________

Witnesses’ Signature

_______________________________________

Witnesses’ Printed Name

_______________________________________

Witnesses’ Address

I declare that the person who signed or acknowledged this document is personally known to me,

that he/she signed or acknowledged this Living Will Declaration in my presence, and that he/she

appears to be of sound mind and under no duress, fraud, or undue influence.

________________________________________

Witnesses’ Signature

________________________________________

Witnesses’ Printed Name

________________________________________

Witnesses’ Address

Page 2 of 2

Illness And Hospitalization Living Will Form Page 2