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Kentucky Execution of this document restricts withholding and withdrawing of some medical procedures. Consult Kentucky Revised Statutes or your attorney. -2- ve. Done this ________________ day of __________, 20____ ________________________________________________ Signature of Notary Public or other officer. Date commission expires:________________________ thority, came the grantor who is of sound mind and eighteen (18) years of age, or older, and acknowledged that he voluntarily dated and signed this writing or directed it to be signed and dated as abo_________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ OR STATE OF KENTUCKY) ______________.County) Before me, the undersigned au________________________________________ (Witness Signature) Print Name: ___________________________________ -1- Address: ______________________________________ ____________________________________n our joint presence, the grantor, who is of sound mind and eighteen (18) years of age, or older, voluntarily dated and signed this writing or directed it to be dated and signed for the grantor. _____this ____________ day of ____________ 20_____ Signed: ____________________________________________________________________ Address: __________________________________________________________________ I of my body upon death. (Optional) Additional Instructions (or write none): I understand the full import of this directive and I am emotionally and mentally competent to make this directive. Signed my wishes as indicated below: _________ Authorize the giving of all or any part of my body upon death for any purpose specified in KRS 311.185. _________ DO NOT authorize the giving of all or any partas my health care surrogate(s). Any prior designation is revoked. It is my intention that my attending physician(s), my family, and my surrogate honor this designation. My surrogate shall comply with designation when I no longer have decisional capacity. If __________________________________________________ refuses or is not able to act for me, I designate ________________________________________ tion, or become permanently unconscious. I Designate ______________________________________________________ as my health care surrogate(s) to make health care decisions for me in accordance with this dlegalforms.com -2- Health Care Surrogate Designation By checking and initialing the appropriate lines below I am indicating my wishes, if I no longer have decisional capacity, have a terminal condi possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at finigning this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Anytax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or s have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or ss related to the grantor -1- within the fourth degree of consanguinity or affinity or a member of the same religious order. [_] These forms are provided "as is" and no implied or express warrantiesogate to make a health care decision. (4) An employee, owner, director, or officer of a health care facility where the grantor is a resident or patient shall not be designated or act as surrogate unleresign at any time by giving written notice to the grantor; to the immediate successor surrogate, if any; to the attending physician; and to any health care facility which is then waiting for the surrd) An attending physician of the grantor; or (e) Any person directly financially responsible for the grantor's health care. (3) A person designated as a surrogate pursuant to an advance directive may f the grantor under descent and distribution statutes of the Commonwealth; (c) An employee of a health care facility in which the grantor is a patient, unless the employee serves as a notary public; (tness to or serve as a notary public or other person authorized to administer oaths in regard to any advance directive made under this section: (a) A blood relative of the grantor; (b) A beneficiary omore adults in the presence of the grantor and in the presence of each other, or acknowledged before a notary public or other person authorized to administer oaths. None of the following shall be a wialid, that invalidity shall not affect the directive. (2) An advance directive shall be in writing, dated, and signed by the grantor, or at the grantor's direction, and either witnessed by two (2) or which are in accordance with accepted medical practice and not specifically prohibited by any other statute. If any other specific directions are held by a court of appropriate jurisdiction to be invealth Care Form. 311.625 Form of living will directive (1) A living will directive made pursuant to KRS 311.623 shall be substantially in the following form, and may include other specific directionsey for Health Care) is based in part on Kentucky Statutes Chapter 311 Section 623 et. Seq. The following are useful excerpts from the Kentucky Statutes relating to the Kentucky Power of Attorney for Hignation (Power of Attorney for Health Care); (2) Kent ucky Health Care Surrogate Designation (Power of Attorney for Health Care) Form. This Kentucky Health Care Surrogate Designation (Power of AttornInformation and Instructions Kentucky Health Care Surrogate Designation (Power of Attorney for Health Care) This package contains (1) Information and Instruction for Kentucky Health Care Surrogate Des Kentucky