Health Care Power Of Attorney Page 10
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12P
III:
D
B
F
A
ART
ISPOSITION OF
ODY AND
UNERAL
RRANGEMENTS
I want the following person to make decisions about the disposition of my body
and my funeral arrangements: (Either initial the first or fill in the second.)
The health care agent who I named in my advance directive.
✎______________
>>OR<<
This person:
Name:
Address:
Telephone Number(s):
(Home and Cell)
If I have written my wishes below, they should be followed. If not, the person I have
named should decide based on conversations we have had, my religious or other beliefs
and values, my personality, and how I reacted to other peoples’ funeral arrangements.
My wishes about the disposition of my body and my funeral arrangements are:
P
IV:
S
W
ART
IGNATURE AND
ITNESSES
By signing below, I indicate that I am emotionally and mentally competent to make this
donation and that I understand the purpose and effect of this document.
(Signature of Donor)
(Date)
The Donor signed or acknowledged signing the foregoing document in my presence
and, based upon personal observation, appears to be emotionally and mentally
competent to make this donation.
(Signature of Witness)
(Date)
Telephone Number(s):
(Signature of Witness)
(Date)
Telephone Number(s):
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