Hawaii Advance Health Care Directive Page 6
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8(12) EFFECT OF COPY: A copy of this form has the same effect as the original.
(13) SIGNATURES: Sign and date the form here:
(date)
(sign your name)
(print your name)
(address)
(city)
(state)
(14) WITNESSES: This power of attorney will not be valid for making health-care
decisions unless it is either (a) signed by two qualified adult witnesses who are personally
known to you and who are present when you sign or acknowledge your signature; or (b)
acknowledged before a notary public in the State.
ALTERNATIVE NO. 1
Witness
I declare under penalty of false swearing pursuant to section 710-1062, Hawaii Revised
Statutes, that the principal is personally known to me, that the principal signed or
acknowledged this power of attorney in my presence, that the principal appears to be of
sound mind and under no duress, fraud, or undue influence, that I am not the person
appointed as agent by this document, and that I am not a health-care provider, nor an
employee of a health-care provider or facility. I am not related to the principal by blood,
marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of
the estate of the principal upon the death of the principal under a will now existing or by
operation of law.
(date)
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Parent category: Medical