Wyoming Advance Health Care Directive Form Page 7
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7SIGNATURES OF WITNESSES or NOTARY PUBLIC
:
I declare under penalty of perjury under the laws of Wyoming that the person who
signed or acknowledged this document is known to me to be the principal, and that the
principal signed or acknowledged this document in my presence.
Please Note: Under Wyoming State Statute 35-22-403 (b), a witness may not be a
treating health care provider, operator of a treating health care facility or an employee of
a treating health care facility.
First witness
______________________________________________________________________
(print witness’ name)
(address)
______________________________________________________________________
(signature of witness)
(date)
Second witness
______________________________________________________________________
(print witness’ name)
(address)
______________________________________________________________________
(signature of witness)
(date)
OR
Notary (in lieu of witnesses)
State of Wyoming
}
County of________________
SS.
Subscribed and sworn to and acknowledged before me by_______________________,
the Principal, this _________ day of _________________________, ______________.
My commission expires: _________________________________________________.
________________________________
Notary Public’s signature
7
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