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ROBERT L. EHRLICH, JR., Governor Ch. 522
MY BODY AND MY FUNERAL ARRANGEMENTS:
(EITHER INITIAL THE FIRST OR FILL IN THE SECOND.)
THE HEALTH CARE AGENT WHO I NAMED IN MY ADVANCE DIRECTIVE.
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THIS PERSON:
NAME:_________________________
ADDRESS:
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TELEPHONE NUMBERS:_______________________________________________________
(HOME AND CELL)
IF I HAVE WRITTEN MY WISHES BELOW, THEY SHOULD RE FOLLOWED. IF NOT, THE
PERSON I HAVE NAMED SHOULD DECIDE BASED ON CONVERSATIONS WE HAVE HAD,
MY RELIGIOUS OR OTHER BELIEFS AND VALUES, MY PERSONALITY, AND HOW I
REACTED TO OTHER PEOPLES' FUNERAL ARRANGEMENTS. MY WISHES ABOUT THE
DISPOSITION OF MY BODY AND MY FUNERAL ARRANGEMENTS ARE:
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PART III IV: SIGNATURE AND WITNESSES
BY SIGNING BELOW, I INDICATE THAT I AM EMOTIONALLY AND MENTALLY
COMPETENT TO MAKE THIS DONATION AND THAT I UNDERSTAND THE PURPOSE AND
EFFECT OF THIS DOCUMENT.
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(SIGNATURE OF DONOR) (DATE)
THE DONOR SIGNED OR ACKNOWLEDGED SIGNING THIS DONATION DOCUMENT IN
MY PRESENCE AND, BASED UPON PERSONAL OBSERVATION, APPEARS TO BE
EMOTIONALLY AND MENTALLY COMPETENT TO MAKE THIS DONATION.
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(SIGNATURE OF DONOR) (DATE)
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TELEPHONE NUMBER(S)
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(SIGNATURE OF WITNESS) (DATE)
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- 2593 -
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