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Arkansas Living Will and Durable Power of Attorney for Health Care Form

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Arkansas Living Will and Durable Power of Attorney for Health Care Form Page 3
Arkansas Living Will and Durable Power of Attorney for Health Care Form
Section 2
: Artificial Nutrition and Hydration
I understand that Arkansas law requires me to make my wishes regarding artificial nutrition and hydration
known separately from the above directions. Therefore, by initialing the appropriate line(s) below, I
specifically:
_______ DIRECT that artificial nutrition
may be withheld or withdrawn after consultation
with my attending physician.
_______ DIRECT that artificial hydration
may be withheld or withdrawn after consultation
with my attending physician.
SIGNED this _____________ day of ______________________________, 20____.
________________________________________
Signature
We, the undersigned, do hereby certify that the Declarant, ______________________________
subscribed this Declaration of Living Will in our presence, and we, at his or her request, in his or her
presence, and in the presence of each other, signed as attesting witnesses, and we do further certify that
the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without undue
influence, fraud or restraint and that his or her signature was voluntary.
____________________________________ _____________________________________
Witness Witness
____________________________________ _____________________________________
Address Address
____________________________________ _____________________________________
City, State and Zip Code City, State and Zip Code
Page 2
Arkansas Living Will and Durable Power of Attorney for Health Care Form