The Minnesota Health Care Directive Page 12
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16PART III: Making This Document Legal
My signature/
I agree with everything in this document and have made this document
mark and
willingly:
date
My signature: ____________________________________________
Date: ___________________________________________________
(day / month / year)
Notary Public OR Witnesses
STATE OF MINNESOTA
Notary Public
NOTE: Must
County of ______________________
not be named
as agent or
This document was signed or acknowledged before me this _______
alternate
(day)
agent.
of _________________ , _______ by the above named principal.
(month)
(year)
____________________________
Signature of Notary Public
This document was signed or acknowledged in my presence. I am not
Two
an agent or alternate agent in this document.
Witnesses
NOTE: Only
Witness Signature: ________________________________________
one witness
Address: ________________________________________________
can be a direct
________________________________________________________
care provider
Date: ___________________________________________________
or employee
(month / day / year)
of a provider
on the day this
Witness Signature: ________________________________________
is signed.
Address: ________________________________________________
________________________________________________________
Date: ___________________________________________________
(month / day / year)
Minnesota Health Care Directive / 4 of 4 pages
Current as of 2008: :mss:Stum103-f
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