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Missouri pires: -2- fixed my official seal in the County of __________________________, State of Missouri, the day and year first above written. ___________________________________________ Notary Public My Commission Exbe the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. IN WITNESS WHEREOF, I have hereunto set my hand and afcipal) STATE OF MISSOURI COUNTY OF ) ) SS ) On this _____day of _________________ (mo nth), __________ (year), before me personally appeared _______________________________________, to me known to erein expressed, and that I am eighteen years of age or older, of sound mind, and under no constraint or undue influence. ________________________________________________________________________ (Prin____ day of _________, 20 _____, and being first duly sworn, do hereby declare to the undersigned authority that I sign it willingly, that I execute it as my free and voluntary act for the purposes thegarding artificially supplied nutrition and hydration in all medical circumstances. I, __________________________________________________________,the principal, sign my name to this instrument this _l health care decisions for me, including decisions to withhold or withdraw any form of life support. I expressly authorize my attorney in fact (and alternate attorney in fact) to make all decisions ris determination of incapacity shall be periodically reviewed by my attending physician and my attorney in fact. -1- I authorize my attorney in fact and successor attorney in fact to make any and aled physicians that I am incapacitated and can no longer make my own medical decisions. The powers and duties of my attorney in fact shall cease upon certification that I am no longer incapacitated. ThR VOIDABLE IF I AM OR BECOME DISABLED OR INCAPACITATED OR IN THE EVENT OF LATER UNCERTAINTY AS TO WHETHER I AM DEAD OR ALIVE. This power of attorney becomes effective upon certification by two licens_____________________________________________ (home phone) (work phone) THIS IS A DURABLE POWER OF ATTORNEY, AND THE AUTHORITY OF MY ATTORNEY IN FACT, WHEN EFFECTIVE, SHALL NOT TERMINATE OR BE VOID O__________________________________________________ (name of alternate attorney in fact) ________________________________________________________________________ (address) ___________________________ (home phone) (work phone) as my attorney in fact. In the event the person I designate above is unable, unwilling or unavailable to act as my attorney in fact, I hereby appoint _____________________________________ (name of attorney in fact) ________________________________________________________________________ (address) __________________________________________________________________________________________________________ (name of principal) ________________________________________________________________________ (address) hereby designate ___________________________________________e purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Missouri Durable Power of Attorney for Health Care I, ____________________________________signing 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. Thegal 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 Missouri Durable Power of Attorney for Health Care Information This package contains the Missouri Durable Power of Attorney for Health Care. These forms are not intended and are not a substitute for l Missouri