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_SETUP.1
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15000.BLD
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1997-07-22
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#15000
@001 State the name of the principal (person giving power):
~Enter the name of the principal, that is, the person who is
~granting this power of attorney.
@440 Enter the place of residence of the principal:
~Enter the city and state where the principal resides. For
~example: East West Northsouth, Idaho
@441 State the name of the attorney:
~Enter the name of the person who will make health care decisions
~for you if you become incapacitated.
@442 Enter the place of residence of the attorney:
~Enter the city, state where the person receiving the power
~lives.
#15047
@449 Enter the beginning date of the power of attorney:
~Enter the date when this power takes effect. This may be entered
~in any desired format.
@450 Enter the ending date of the power of attorney:
~Enter the date when this power will end. This may be entered in
~any convenient format.
@003 Enter the state where signed:
~Enter the state where this power is being signed.
@004 Enter the county where signed:
~Enter the county where this power is being signed.
#end control section
#15000
/* 15000.arm--- Special poa for health care */
POWER OF ATTORNEY
@001, the "principal," of @440, herewith appoints @441
of @442, as their attorney in fact, to act in the place and
stead and with the same authority as Principal would have to
do the following acts:
In the event of my incapacity, to act in my place regarding any
and all health care decisions for me, including the type of
treatment, location of treatment, and in addition, the right
to refuse or decline life prolonging treatment and to direct
that any care which I receive be solely to alleviate pain.
My attorney shall have the power of substitution.
This is a durable power of attorney and shall not terminate upon
my incapacity.
#15047
/* Para. 15407: End of poa */
This power of attorney shall be in effect from @449 to @450.
However, should I be incapacitated or incompetent at the time
stated for expiration (@450), this power shall extend until
I am no longer incapacitated.
_____________________________________________________
@001, As Principal
STATE OF @003
COUNTY OF @004
@001 personally appeared before me and acknowledged
the execution of this power of attorney for the purposes set
forth therein.
Dated: _______________________________
__________________________________________
Notary Public