S.B. 664                                                         VETOES

BY SIGNING BELOW, I INDICATE THAT I AM EMOTIONALLY AND MENTALLY
COMPETENT TO MAKE THIS LIVING WILL AND THAT I UNDERSTAND ITS PURPOSE
AND EFFECT.

(DATE)                                                              (SIGNATURE OF DECLARANT)

THE DECLARANT SIGNED OR ACKNOWLEDGED SIGNING THIS LIVING WILL IN
MY PRESENCE AND BASED UPON MY PERSONAL OBSERVATION THE DECLARANT
APPEARS TO BE A COMPETENT INDIVIDUAL.

(SIGNATURE OF TWO WITNESSES OR A NOTARY PUBLIC)

(WITNESS)                                                                                     (WITNESS)

SIGNATURE OF TWO WITNESSES

FORM II

ADVANCE DIRECTIVE

PART A

APPOINTMENT OF HEALTH CARE AGENT

(OPTIONAL FORM)

(CROSS THROUGH IF YOU DO NOT WANT TO APPOINT A HEALTH CARE AGENT TO
MAKE HEALTH CARE DECISIONS FOR YOU. IF YOU DO WANT TO APPOINT AN AGENT,
CROSS THROUGH ANY ITEMS IN THE FORM THAT YOU DO NOT WANT TO APPLY.)

(1)     I, ______, RESIDING AT

APPOINT THE FOLLOWING INDIVIDUAL AS MY AGENT TO MAKE HEALTH CARE
DECISIONS FOR ME

(FULL NAME, ADDRESS, AND TELEPHONE NUMBER)

OPTIONAL: IF THIS AGENT IS UNAVAILABLE OR IS UNABLE OR UNWILLING TO ACT
AS MY AGENT, THEN I APPOINT THE FOLLOWING PERSON TO ACT IN THIS CAPACITY

(FULL NAME, ADDRESS, AND TELEPHONE NUMBER)

(2) MY AGENT HAS FULL POWER AND AUTHORITY TO MAKE HEALTH
CARE DECISIONS FOR ME, INCLUDING THE POWER TO:

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