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Nebraska _________________ Address: ______________________________________ OR The Declarant voluntarily signed this writing in my presence. ______________________________________ (Notary Public) ature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ______________________________________________ Address: ______________________________________ The Declarant voluntarily signed this writing in my presence. _____________________________________________ (Witness Signtreatment that is not necessary for my comfort or to alleviate pain. Signed this _____ day of _________., 20___ __________________________________________ (Declarant's Signature) Print Name: _______e and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Rights of the Terminally Ill Act, to withho ld or withdraw life sustaining have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short timal. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION If I should lapse into a persistent vegetative state or io n. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professione to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situatd 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 tax advice. Laws vary from tim other health care provider shall make the revocation a part of the declarant's medical record. [_] These forms are provided "as is" and no implied or express warranties have been made or are providendition. A revocation shall be effective upon its communication to the attending physician or other health care provider by the declarant or a witness to the revocation. (2) The attending physician ornsfer requirements of section 20-409. 20-406 - Revocation of declaration (1) A declarant may revoke a declaration at any time and in any manner without regard to the declarant's mental or physical co to invoke the patient's declaration. When the declaration becomes operative, the attending physician and other health care providers shall act in accordance with its provisions or comply with the tralife-sustaining treatment, and (4) the attending physician has notified a reasonably available member of the declarant's immediate family or guardian, if any, of his or her diagnosis and of the intentding physician to be in a terminal condition or in a persistent vegetative state, (3) the declarant is determined by the attending physician to be unable to make decisions regarding administration of so advise the declarant. 20-405 - When declaration operative A declaration shall become operative when (1) it is communicated to the attending physician, (2) the Declarant is determined by the attenysician or other health care provider who is furnished a copy of the declaration shall make it a part of the declarant's medical record and, if unwilling to comply with the declaration, shall promptlyl Information & Instructions ­ Page 3 (2) A declaration directing a physician to withhold or withdraw life-sustaining treatment may, but need not, be in the form provided in this subsection. (3) A phclarant, and no witness shall be an employee of a life or health insurance provider for the declarant. The restrictions upon who may witness the signing shall not apply to a notary public. Living Wildirection and witnessed by two adults or a notary public. No more than one witness to a declaration shall be an administrator or employee of a health care provider who is caring for or treating the ded mind may execute at any time a declaration governing the withholding or withdrawal of life-sustaining treatment. The declaration must be signed by the declarant or another person at the declarant's ning treatment, will, in the opinion of the attending physician, result in death within a relatively short time. 20-404 - Declaration relating to use of life-sustaining treatment (1) An adult of souny or insular possession subject to the jurisdiction of the United States; and (11) Terminal condition shall mean an incurable and irreversible condition that, without the administration of life-sustaig physician to be in a terminal condition or a persistent vegetative state; (10) State shall mean a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territor(8) Physician shall mean an individual licensed to practice medicine in this state; (9) Qualified patient shall mean an adult who has executed a declaration and who has been determined by the attendinl, corporation, business trust, estate, trust, partnership, limited liability company, association, joint venture, government, governmental subdivision or agency, or other legal or commercial entity; is characterized by a total and irreversible loss of consciousness and capacity for cognitive interaction with the environment and no reasonable hope of improvement; (7) Person shall mean an individuagetative state; (6) Persistent vegetative state shall mean a medical condition that, to a reasonable degree of medical certainty as determined in accordance with currently accepted medical standards, nt shall mean any medical procedure or intervention that, when administered to a qualified patient, will serve only to prolong the process of dying or maintain the qualified patient in a persistent veerson who is licensed, certified, or otherwise authorized by the law of this state to administer health care in the ordinary course of business or practice of a profession; (5) Life-sustaining treatmeWill Information & Instructions ­ Page 2 (3) Declaration shall mean a writing executed in accordance with the requirements of subsection (1) of section 20-404; (4) Health care provider shall mean a pwho is nineteen years of age or older or who is or has been married; (2) Attending physician shall mean the physician who has primary responsibility for the treatment and care of the patient; Living restricted by the Rights of the Terminally Ill Act. 20-403 - Definitions For purposes of the Rights of the Terminally Ill Act, unless the context otherwise requires: (1) Adult shall mean any person he patient or the patient's next of kin. Remedy in law and equity may be granted by a court of competent jurisdiction. (2) It is the public policy of this state that no existing right be terminated orvide one means, by use of the declaration described in the act, for people to exercise their rights. Unjustifiable violation of a patient's direction shall be a civil cause of action maintainable by tg life, preventing homicide and suicide, protecting dependent third parties, and maintaining the integrity of the medical profession. The Legislature adopts the Rights of the Terminally Ill Act to proright and a constitutionally protected liberty interest for people to direct their medical treatment. The exercise of such right and liberty interest is subject to certain state interests in preservin 20-401 - Act, how cited Sections 20-401 to 20-416 shall be known and may be cited as the Rights of the Terminally Ill Act. 20-402 - Statement of policy (1) The Legislature recognizes the common-law braska Living Will is based on Chapter 20 Section 20-401 et. Seq. of the Nebraska Statutes. For your convenience, we have included useful excerpts from the Nebraska Statutes relating to Living Wills. ___ Signature of Notary Public -2- Information and Instructions Nebraska Living Will This package contains (1) Information and Instruction for Nebraska Living Will; (2) Nebraska Living Will. This Ne by this power of attorney for health care. Witness my hand and notarial seal at _______________________________ in such county the day and year last above written. Seal ____________________________uress or undue influence, that he or she acknowledges the execution of the same to be his or her voluntary act and deed, and that I am not the attorney in fact or successor attorney in fact designated personally to me known to be the identical person whose name is affixed to the above power of attorney for health care as principal, and I declare that he or she appears in sound mind and not under dy of ________ , 20 ___, before me, ________________________________________________________, a notary public in and for ________________________ County, personally came ______________________________,______________ Date: _________________________________ Date: _________________________________ OR State of Nebraska, ) ) ss. County of ___________________ ) On this _______________________________ da_________________________________ ______________________________________ (Witness Signature) (Witness Signature) Print Name: Print Name: ______________________________________ ________________________ of sound mind and not under duress or undue influence, and that neither of us nor the principal's attending physician is the person appointed as attorney in fact by this document. Witnessed By: _____that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to beE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN. _____________________________________ Signature of person making designation/date) -1- DECLARATION OF WITNESSES We declare AT ANY TIME BY NOTIFYING MY ATTORNEY IN FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT TH UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE___________________________________________________________________ ______________________________________________________________________________ I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I__________________________________________________ I direct that my attorney in fact comply with the following instructions on artificially administered nutrition and hydration (optional): ___________rney in fact comply with the following instructions on life-sustaining treatment (optional): ______________________________________________________________________________ ____________________________ions or limitations: ______________________________________________________________________________ ______________________________________________________________________________ I direct that my atto read the warning which accompanies this document and understand the consequences of executing a power of attorney for health care. I direct that my attorney in fact comply with the following instructact for health care. I authorize my attorney in fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions. I have_____________________________________ ,whose address is __________________________________________________, and whose telephone number is _______________________________, as my successor attorney in f, whose address is __________________________________________________, and whose telephone number is _______________________________, as my attorney in fact for health care. I appoint ________________d use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Power of Attorney for Health Care I appoint _____________________________________________________ sult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. -2- [_] The purchase and 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 con[_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and shoul [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. hall continue in effect until the principal's death, until revoked pursuant to section 30-3420, or until the attorney in fact and any successor attorney in fact withdraws pursuant to section 30-3407. h care which is executed in another state and is valid under the laws of that state shall be valid according to its terms. 30-3410 - Power of attorney; duration. A power of attorney for health care ssection 30-3404. (3) A power of attorney for health care executed prior to January 1, 1993, shall be effective if it fully complies with the terms of section 30-3404. (4) A power of attorney for healtr the Uniform Durable Power of Attorney Act or in any other form if the power of attorney for health care included in such durable power of attorney or any other form fully complies with the terms of which complies with sections 30-3401 to 30-3432 and may be in the form provided in this subsection. (2) A power of attorney for health care may be included in a durable power of attorney drafted unden substantially the form prescribed in section 30-3408. 30-3408 - Power of attorney; form; validity. (1) A power of attorney for health care executed on or after September 9, 1993, shall be in a formthe principal. No more than one witness may be an administrator or employee of a health care provider who is caring for or treating the principal. (2) Each witness shall make the written declaration int, child, grandchild, sibling, presumptive heir, known devisee at -1- the time of the witnessing, attending physician, or attorney in fact; or an employee of a life or health insurance provider for fact or successor attorney in fact. 30-3405 - Witness; disqualification; declaration. (1) The following shall not qualify to witness a power of attorney for health care: The principal's spouse, pareney for health care by the principal or the principal's acknowledgment of the signature and date, or be signed and acknowledged by the principal before a notary public who shall not be the attorney inevent the principal is incapable, (4) show the date of its execution, and (5) be witnessed and signed by at least two adults, each of whom witnesses either the signing and dating of the power of attorentify the principal, the attorney in fact, and the successor attorney in fact, if any, (3) specifically authorize the attorney in fact to make health care decisions on behalf of the principal in the ult has been adjudged incompetent or unless a guardian has been appointed for such adult. 30-3404 - Power of attorney; contents. The power of attorney for he alth care shall (1) be in writing, (2) iduthority of the original designee shall commence. (2) There shall be a rebuttable presumption that every adult is competent for purposes of executing a power of attorney for health care unless such adr attorney in fact has commenced, the original attorney in fact becomes available, able, and willing to serve as attorney in fact, the authority of the successor attorney in fact shall cease and the an place of the original attorney in fact when the original attorney in fact is not reasonably available or is unable or unwilling to serve as an attorney in fact. If, after the authority of a successont adult as attorney in fact for health care decisions in accordance with sections 30-3401 to 30-3432. A principal may also designate another competent adult as a successor attorney in fact to serve iHealth Care Form. 30-3403 - Power of attorney for health care; designation; competency; presumption. (1) A principal may confer a power of attorney for health care thereby designating another competey for Health Care is based on Chapter 30 Section 30-3410 et. Seq. of the Nebraska Statutes. The following are useful excerpts from the Nebraska Statutes relating to the Nebraska Power of Attorney for or Health Care This package contains (1) Information and Instruction for Nebraska Power of Attorney for Health Care; (2) Nebraska Power of Attorney for Health Care Form. This Nebraska Power of Attorne with a tax professiona l. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Nebraska Power of Attorney f your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussedice. 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 or signed without consulting an attorney first to make sure it fitseen 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 tax advHealth Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have bNebraska Advance Health Care Directive This package contains both a Nebraska Power of Attorney for Health Care and a Nebraska Living Will. Together these forms are also sometimes known as an Advance Nebraska