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Power of Attorney for Health Care
1.I appoint _______________________________________________, whose address is
_____________________________________________________________ and whose
telephone number is ___________________________ as my attorney-in-fact for health
care. I appoint ________________________________________, whose address is
__________________________________________, and whose telephone number is
_________________, as my successor attorney-in-fact for health care. I authorize my
attorney-in-fact appointed by this document to make health care decisions for me when I
am determined to be incapable of making my own health care decisions. I have read the
warning which accompanies this document and understand the consequences of executing
a power of attorney for health care.
2.I direct that my attorney-in-fact comply with the following instructions or limitations:
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