HEALTH CARE DIRECTIVE



HEALTH CARE DIRECTIVE

|You |

|Do you wish to donate your organs, tissues and other body parts after your death? |

|yes no |

|Do you wish to donate your remains to science as an anatomical gift for the purposes of teaching health care professionals after your |

|death? yes no |

|Do you wish to be buried cremated |

|Any special instructions? ____________________________________________________ |

|If not required by law, do you wish to have a post mortem examination (autopsy) performed for the purposes of diagnosis, medical education|

|and research? yes no |

|Do you wish to give your power of attorney power to override your decision to donate your organs? yes no |

|Spouse |

|Do you wish to donate your organs, tissues and other body parts after your death? |

|yes no |

|Do you wish to donate your remains to science as an anatomical gift for the purposes of teaching health care professionals after your |

|death? yes no |

|Do you wish to be buried cremated |

|Any special instructions? ____________________________________________________ |

|If not required by law, do you wish to have a post mortem examination (autopsy) performed for the purposes of diagnosis, medical education|

|and research? yes no |

|Do you wish to give your power of attorney power to override your decision to donate your organs? yes no |

|POWER OF ATTORNEY FOR THE HEALTH CARE DIRECTIVE |

|You |

|To grant to the attorney-in-fact any of the following powers, make a check or "x" on the line in front of each power being granted. |

|real property transactions; I choose to limit this power to real property: _________________________________________________ |

|tangible personal property transactions; |

|bond, share, and commodity transactions; |

|banking transactions; |

|business operating transactions; |

|insurance transactions; |

|beneficiary transactions; |

|gift transactions; |

|fiduciary transactions; |

|claims and litigation; |

|family maintenance; |

|benefits from military service; |

|records, reports, and statements; |

|all of the powers listed in (A) through (M) above and all other matters. |

|2. Should the Power of Attorney continue if you become incapacitated or incompetent? |

|yes no |

|Should this Power of Attorney authorize the attorney-in-fact to transfer property to the attorney-in-fact? yes no |

|Unless you request it, does your attorney-in-fact need to render accounting to you or your estate? yes no |

|Spouse |

|To grant to the attorney-in-fact any of the following powers, make a check or "x" on the line in front of each power being granted. |

|real property transactions; I choose to limit this power to real property: _________________________________________________ |

|tangible personal property transactions; |

|bond, share, and commodity transactions; |

|banking transactions; |

|business operating transactions; |

|insurance transactions; |

|beneficiary transactions; |

|gift transactions; |

|fiduciary transactions; |

|claims and litigation; |

|family maintenance; |

|benefits from military service; |

|records, reports, and statements; |

|all of the powers listed in (A) through (M) above and all other matters. |

|2. Should the Power of Attorney continue if you become incapacitated or incompetent? |

|yes no |

|Should this Power of Attorney authorize the attorney-in-fact to transfer property to the attorney-in-fact? yes no |

|Unless you request it, does your attorney-in-fact need to render accounting to you or your estate? yes no |

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