Durable Power Of Attorney For Health Care Decisions Page 12
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12(3) an employee of the health care institution or health care facility where the principal
is receiving health care; or
(4) the person appointed as agent by this document.
Signature of Second Witness
Date
Printed Name
Address
City
State
Zip
ALTERNATIVE NO. 2
A
N
P
CKNOWLEDGEMENT BY
OTARY
UBLIC
State of Alaska ________________ Judicial District
On this ____ day of ___________________, in the year ______________, before me,
__________________________________________ (
) appeared
name of notary public
__________________________________________, personally known to me (or proved to me on the
basis of satisfactory evidence) to be the person whose name is subscribed to this instrument,
and acknowledged that the person executed it.
(Seal)
____________________________________________
Signature of Notary Public
12
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