Georgia Advanced Directives For Health Care Form (Page 9 of 9) in pdf

Georgia Advanced Directives For Health Care Form Page 9

Cannot be a person who was selected to be your health care

agent or back-up health care

agent in PART ONE;

Cannot be a person who will knowingly inherit anythingfrom you

or otherwise htowingty

gain afinancial benefitfrom your death; or

cannot be a person who is directly involved in your health care.

only one of the witnesses may be an employee, agent, or medical

staff member of the hospital,

skilled nursingfacility, hospice, or other iealth caifacility

in which you are receivtng health care

(but this witness cannot be directly involved in youihealtiz

care.)

By signing below, I state that r am emotionally and mentally

capable of making this advance

directive for health care andthat I understand its purpose and effect.

Date

The declarant signed this forrn in my presence or acknowledged signing

this form to me. Based on

mypersonal observation, the declarant appeared to be emotionally

andlentally capable of making

this advance directive for health care andligned this forrn willingly

and voluntarily.

Dated this:

A r{r{reoo

^s wv oo

address

Page 9 of9 paggs.

Georgia Advanced Directives For Health Care Form Page 9