Power of attorney.
State the name of the principal (person giving power), the "principal," of Enter the place of residence of the principal, herewith appoints State the name of the attorney of Enter the place of residence of the attorney, as their attorney in fact, to act in the place and stead and with the same authority as Principal would have to do the following acts:
In the event of my incapacity, to act in my place regarding any and all health care decisions for me, including the type of treatment, location of treatment, and in addition, the right to refuse or decline life prolonging treatment and to direct that any care which I receive be solely to alleviate pain.
My attorney shall have the power of substitution.
This is a durable power of attorney and shall not terminate upon my incapacity.
This power of attorney shall be in effect from Enter the beginning date of the power of attorney to Enter the ending date of the power of attorney. However, should I be incapacitated or incompetent at the time stated for expiration (Enter the ending date of the power of attorney), this power shall extend until I am no longer incapacitated.
State the name of the principal (person giving power), As Principal
STATE OF Enter the state where signed
COUNTY OF Enter the county where signed
State the name of the principal (person giving power) personally appeared before me and acknowledged the execution of this power of attorney for the purposes set forth therein.