Durable Power Of Attorney For Health Care - State Of Georgia (Page 3 of 7) in pdf

Durable Power Of Attorney For Health Care - State Of Georgia Page 3

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

FOR USE IN GEORGIA

I, ________________________________, hereby declare as follows:

Appointment of Agent: In recognition of the fact that there may come a time when I will become

unable to make my own health care decisions because of illness, injury or other circumstances, I hereby

appoint

Agent

Name of Agent:

__________________________________________________________

Address:

___________________________________________________________

Telephone: Day:

Evening:

____________________________

___________________________

as my agent (“agent”) to make any and all health care decisions for me, consistent with my wishes as set forth

in this directive.

If the person named above is unable, unwilling or unavailable to act as my agent, I hereby appoint

Successor

Name of Successor Agent:

Agent

___________________________________________________________

Address:

___________________________________________________________

Telephone: Day:

Evening:

____________________________

___________________________

to serve in such capacity.

This appointment shall take effect in the event I become unable, because of illness, injury or other

circumstances, to make my own health care decisions.

Jewish Law to Govern Health Care Decisions: I am Jewish. It is my desire, and I hereby direct,

that all health care decisions made for me be made pursuant to Jewish law and custom as determined in

accordance with strict Orthodox interpretation and tradition. Without limiting in any way the generality of the

foregoing, it is my wish that Jewish law and custom should dictate the course of my health care with respect to

such matters as the performance of cardio-pulmonary resuscitation if I suffer cardiac or respiratory arrest; the

performance of life-sustaining surgical procedures and the initiation or maintenance of any particular course of

life-sustaining medical treatment or other form of life-support maintenance, including the provision of

nutrition and hydration; and the criteria by which death shall be determined, including the method by which

such criteria shall be medically ascertained or confirmed.

Durable Power Of Attorney For Health Care - State Of Georgia Page 3