Logan County Advance Directive Form (Page 3 of 4) in pdf

DESIGNATION OF A CONSERVATOR OF MY PERSON

If a conservator of my person should be needed, I designate that____________________________

be appointed my conservator. If _____________________________________ is unwilling or unable

to serve as my conservator, I designate ____________________________________. No bond shall

be required of either person in any jurisdiction.

Being of sound mind, these requests, appointments, and designations are made after careful

reflection. Any party receiving a duly executed copy or facsimile of this document may rely upon it

unless such party has received actual notice of my revocation of said document.

Signature ________________________

Date _________________________

STATE OF ILLINOIS

)

: ss

COUNTY OF LOGAN

)

Personally appeared ________________________________, signer of the foregoing instrument, and

acknowledged the same to be his/her free act and deed, before me this ______________ day

of_____________, 20_________.

____________________________________________________

Logan County Clerk of the Circuit Court

Notary Public

My Commission Expires ________________________________

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 that this document

was signed. The author of this document appeared to be under no undue influence. We have signed

this document at the author’s request, in the author’s presence, and in the presence of each other.

__________________________________

(Witness)

__________________________________

(Number and Street)

__________________________________

_________________________________

(City, State, and Zip Code)

Pg3

Logan County Advance Directive Form Page 3