Advance Directive To Physicians Page 3
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3e i t h e r o f u s h a v e a n y c l a i m a g a i n s t a n y p o r t i o n o f t h e e s t a t e a t t h i s t i me . N e i t h e r o f u s i s t h e
a t t e n d i n g p h y s i c i a n , a n e mp l o y e e o f t h a t p h y s i c i a n , o r a n e mp l o y e e o f a h e a l t h c a r e f a c i l i t y i n
w h i c h t h e d e c l a r e r i s a p a t i e n t .
Witness 1
Witness 2
S i g n a t u r e :
S i g n a t u r e :
Mike Smith
Bronwyn Tinnis
P r i n t e d N a me :
P r i n t e d N a me :
Mi k e S mi t h
B r o n w y n T i n n i s
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