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Missouri ______________________________________________________ Address ______________________________________________________ -3- ch of the undersigned witnesses is at least eighteen years of age. Witness ______________________________________________________ Address ______________________________________________________ Witnessy, County and State of residence_________________________________ The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence. Eaof dying. Other directions: YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF TWO WITNESSES. Signed this ________ day of __________________ (month, year). Signature _________________________________ Cit, suppress my appetite or my breathing, or be habit-forming. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life, rather only to permit the natural process on, I direct the treatment be withdrawn even if it shortens my life. I also direct that I be given medical treatment to relieve pain or to provide comfort, even if such treatment might shorten my life physician believes that any life-prolonging procedure may lead to a significant recovery, I direct my physician to try the treatment for a reasonable period of time. If it does not improve my conditi or condition, I direct my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. However, if mybe prolonged by administration of death-prolonging procedures. If I am persistently unconscious or there is no reasonable expectation of my recovery from a seriously incapacitating or terminal illnessng the dying process. By this this HEALTH CARE DIRECTIVE ("Directive") I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not _______________________________ Notary Public My Commission Expires: -2- Missouri Health Care Directive I have the primary right to make my own decisions concerning treatment that might unduly prolod deed. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County of __________________________, State of Missouri, the day and year first above written. ____________eared _______________________________________, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act an_________________________________________________________ (principal) STATE OF MISSOURI COUNTY OF ) ) SS ) On this _____day of _________________ (month), __________ (year), before me personally applingly, that I execute it as my free and voluntary act for the purposes therein expressed, and that I am eighteen years of age or older, of sound mind, and under no constraint or undue influence. ________________________,the principal, sign my name to this instrument this _____ day of _________, 20 _____, and being first duly sworn, do hereby declare to the undersigned authority that I sign it wil attorney in fact (and alternate attorney in fact) to make all decisions regarding artificially supplied nutrition and hydration in all medical circumstances. I, ______________________________________rize my attorney in fact and successor attorney in fact to make any and all health care decisions for me, including decisions to withhold or withdraw any form of life support. I expressly authorize my fact shall cease upon certification that I am no longer incapacitated. This determination of incapacity shall be periodically reviewed by my attending physician and my attorney in fact. -1- I autho This power of attorney becomes effective upon certification by two licensed physicians that I am incapacitated and can no longer make my own medical decisions. The powers and duties of my attorney inY OF MY ATTORNEY IN FACT, WHEN EFFECTIVE, SHALL NOT TERMINATE OR BE VOID OR VOIDABLE IF I AM OR BECOME DISABLED OR INCAPACITATED OR IN THE EVENT OF LATER UNCERTAINTY AS TO WHETHER I AM DEAD OR ALIVE. ___________________________________ (address) ________________________________________________________________________ (home phone) (work phone) THIS IS A DURABLE POWER OF ATTORNEY, AND THE AUTHORITble to act as my attorney in fact, I hereby appoint ________________________________________________________________________ (name of alternate attorney in fact) _____________________________________ ________________________________________________________________________ (home phone) (work phone) as my attorney in fact. In the event the person I designate above is unable, unwilling or unavaila__ (address) hereby designate __________________________________________________________ (name of attorney in fact) ________________________________________________________________________ (address) Power of Attorney for Health Care I, ______________________________________________________________________ (name of principal) ______________________________________________________________________nsult an attorney whenever a document is negotiated with another party. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Missouri Durableld not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also corective Forms. These forms are not intended and are not a substitute for legal advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and shouMissouri Durable Power of Attorney for Health Care & Missouri Health Care Directive Information This package contains the Missouri Durable Power of Attorney for Health Care and Missouri Health Care Di Missouri