Advance Directive For Health Care (Page 5 of 6) in pdf

Advance Directive For Health Care Page 5

If the time comes for me to stop receiving life sustaining treatment or food and

water through a tube or an IV, I direct that my doctor talk about the good and

bad points of doing this, along with my wishes, with my health care proxy, if I

have one, and with the following people:

____________________________________

Section 4. My signature

Your name: _________________________

The month, day, and year of your birth: ______

Your signature: _______________________

Date signed: _________________________

Section 5. Witnesses (need two witnesses to sign)

I am witnessing this form because I believe this person to be of sound mind. I

did not sign the person's signature, and I am not the health care proxy. I am not

related to the person by blood, adoption, or marriage and not entitled to any

part of his or her estate. I am at least 19 years of age and am not directly

responsible for paying for his or her medical care.

Name of first witness: ___________________

Signature: _____________________________

Date: _______________

Name of second witness: _________________

Signature: _____________________________

Date: _______________

Advance Directive For Health Care Page 5