End-of-Life Medical Decisions Power of Attorney
Principal Information
Full Name
Address
Phone Number
Agent (Attorney-in-Fact) Information
Agent's Full Name
Agent's Address
Agent's Phone Number
Alternate Agent (Optional)
Alternate Agent's Full Name
Alternate Agent's Address
Alternate Agent's Phone Number
Grant of Authority
Specific Rights & Instructions
End-of-Life Decisions
Instructions Regarding Life-Sustaining Treatment
Additional Instructions or Limitations
Effective Date and Duration
This Power of Attorney becomes effective on
And remains in effect until
Signatures
Principal:
Date:
Agent:
Date:
Witness 1:
Date:
Witness 2:
Date:
Notary Acknowledgment (if required)
Notary Public Name
Date
Seal