Advance Directive Form (Page 3 of 3) in pdf

Advance Directive Form Page 3

DURABLE POWER OF ATTORNEY

FOR HEALTH CARE

State of Louisiana

I, __________________________, being of sound mind, do hereby

designate ___________________________ to serve as my attorney-in-fact for the purpose of

making treatment decisions for me should I be diagnosed and certified as having a terminal and

irreversible illness and be incompetent or be in a continual profound comatose state with no

reasonable chance of recovery, or otherwise mentally or physically unable to make such decisions

myself.

Signed:

Date:

_______________________________

____________

City and Parish of Residence:

_______________________________________________________

The declarant has been personally known to me and I believe him or her to be of sound mind.

Witness:

________________________________________________

Witness:

________________________________________________

Sworn and subscribed

before me, this _______ day

of _______________, _______.

________________________________________,

Notary Public

My commission is for life.

Advance Directive Form Page 3