Durable Power Of Attorney For Health Care Page 9
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11Part III. General Provisions included in the Directive
and Durable Power of Attorney (Continued)
YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF TWO WITNESSES.
IN WITNESS WHEREOF, I have executed this document this ______ day of
______________________(month), ______(year).
________________________________________
Signature
Print Name ________________________________________
Address
________________________________________
________________________________________
The person who signed this document is of sound mind and voluntarily signed this document
in our presence. Each of the undersigned witnesses is at least eighteen years of age.
Signature ____________________________
Signature ___________________________
Print Name___________________________
Print Name _________________________
Address ____________________________
Address ____________________________
____________________________
_____________________________
ONLY REQUIRED FOR PART I — DURABLE POWER OF ATTORNEY
STATE OF MISSOURI
)
)
SS
COUNTY OF _______________
)
On this ______ day of _________________ (month), ______ (year), before me personally
appeared ______________________________________, to me known to be the person described
in and who executed the foregoing instrument and acknowledged that he/she executed the same
as his/her free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the
County of ______________________, State of Missouri, the day and year first above written.
___________________________________
Notary Public
My Commission Expires:
15.
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