Living Will Or Health Care Instructions Form/witnesses' Statements Form/witnesses' Affidavits Form Page 2

WITNESSES' STATEMENTS

This document was signed in our presence by _____________________________ the author of

this document, who appeared to be eighteen years of age or older, of sound mind and able to

understand the nature and consequences of health care decisions at the time this document was

signed. The author appeared to be under no improper influence. We have subscribed this

document in the author's presence and at the author's request and in the presence of each

other.

x__________________________

x___________________________

(Witness)

x__________________________

x___________________________

(Number and Street)

x__________________________

x___________________________

(City, State and Zip Code)

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Parent category: Legal