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[If'the'space'below'is'not'sufficient,'you'may'attach'additional'pages.'If'you'do'not'have'any'
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[The'following'persons'CANNOT 'serve'as'a'witness'to'this'Health'Care'Power'of'Attorney:'
• Your'agent,'if'any;'
• The'guardian'of'your'person'or'estate,'if'any;'
• Any'alternate'or'successor'agent'or'guardian,'if'any;'
• Anyone'related'to'you'by'blood,'marriage,'or'adoption'(for'example,'your'spouse'
and'children);'
• Your'attending'physician;'and'
• The'administrator'of'any'nursing'home'where'you'are'receiving'care.]'
'
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I(attest(that(the(principal(signed(or(acknowledged(this(Health(Care(Power(of(Attorney(in(my((
presence,(and(that(the(principal(appears(to(be(of(sound(mind(and(not(under(or(subject(to(duress,(
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©'August'2016.'May'be'rep rin ted 'a nd 'co p ied 'fo r'us e'b y'th e 'pu b lic,'at to rne y s,'m e dic al'a n d'o ste o pa th ic'p h ys icia ns ,''
hospitals,'bar'associations,'medical'societies'and'nonprofit'associations'and'organizations.'It'may'not'be'reproduced'
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