Wyoming AD
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  • 1. INSTRUCTIONS ———— PRINT YOUR NAME AND ADDRESS PRINT NAME, ADDRESS AND TELEPHONE NUMBER OF YOUR ATTORNEY- IN-FACT PRINT NAME, ADDRESS AND TELEPHONE NUMBER OF YOUR ALTERNATE ATTORNEY- IN-FACT © 2000 PARTNERSHIP FOR CARING, INC. WYOMING DURABLE POWER OF ATTORNEY FOR HEALTH CARE ————————————— 1) I, ________________________________________________________________, of (name of principal) ________________________________________________________________________, (address) hereby appoint: ___________________________________________________________ (name of attorney-in-fact) ___________________________________________________________ (address of attorney-in-fact) ___________________________________________________________ (telephone number of attorney-in-fact) as my attorney-in-fact to consent to, or reject, or to withdraw consent for any medical care, treatment, service or procedure. 2) In the event the person I appoint is unable, unwilling or unavailable to act as my attorney-in-fact, I hereby appoint: ___________________________________________________________ (name of successor attorney-in-fact) ___________________________________________________________ (address of successor attorney-in-fact) ___________________________________________________________ (telephone number of successor attorney-in-fact) 3) I authorize my attorney-in-fact and my successor attorney-in-fact to make any and all health care decisions for me, including decisions to withhold or withdraw any form of life-sustaining procedures. 4) This power of attorney becomes effective when I can no longer make my own medical decisions and is not affected by my physical disability or incapacity. The determination of whether I can make my own medical decisions is to be made by my attorney-in-fact, or if he or she is unable, unwilling or unavailable to act, by my successor attorney-in-fact, unless the attending physician determines that I have decisional capacity.
  • 2. PRINT YOUR NAME AND THE DATE SIGN YOUR NAME WITNESSING PROCEDURE ———— YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF EITHER A NOTARY PUBLIC OR TWO WITNESSES NOTARY PUBLIC SIGNS HERE OR © 2000 PARTNERSHIP FOR CARING, INC. I, ________________________________________________, the principal, sign my name to this instrument this _______ day of _______________, 20_____, (date) (month) (year) 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 therein expressed, and that I am eighteen years of age or older, of sound mind, and under no constraint or undue influence. Signature: ____________________________________________________________ The State of Wyoming The County of _______________ Subscribed, sworn to, and acknowledged before me by _________________________________________, the principal, this _______ day of ____________, 20____. (Seal) ______________________________ (notary public) OR WITNESSES’ STATEMENT “I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the principal, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as attorney-in-fact by this document, and that I am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a WYOMING DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 2 OF 3
  • 3. residential care facility, nor an employee of an operator of a residential care facility.” Witness #1: Signature: ____________________________________ Date: _________________ Print Name: __________________________________________________________ Telephone Number: ___________________________________________________ Residence Address: ____________________________________________________ ____________________________________________________ Witness #2: Signature: ____________________________________ Date: _________________ Print Name: __________________________________________________________ Telephone Number: ___________________________________________________ Residence Address: ____________________________________________________ ____________________________________________________ YOUR WITNESSES MUST SIGN AND DATE THE DOCUMENT AND PRINT THEIR NAMES, TELEPHONE NUMBERS AND ADDRESSES © 2000 PARTNERSHIP FOR CARING, INC. WYOMING DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 3 OF 3 Courtesy of Partnership for Caring, Inc. 6/96 1035 30th Street, NW Washington, DC 20007 800-989-9455
  • 4. WYOMING DECLARATION ———————————— Declaration made this ________ day of _____________________, 20________. (date) (month) (year) I, ___________________________________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare: If at any time I should have an incurable injury, disease or other illness certified to be a terminal condition by two (2) physicians who have personally examined me, one (1) of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care. Other instructions: INSTRUCTIONS ———— PRINT THE DATE PRINT YOUR NAME ADD PERSONAL INSTRUCTIONS (IF ANY) © 2000 PARTNERSHIP FOR CARING, INC.
  • 5. If, in spite of this declaration, I am comatose or otherwise unable to make treatment decisions for myself, I HEREBY designate: _______________________________________________________________________ (name of proxy) _______________________________________________________________________ (address of proxy) (telephone number of proxy) to make treatment decisions for me. (Note: Designation of a proxy may, but need not, be included in the Declaration, according to § 35-22-102 of the Wyoming Living Will Act. If you do not wish to use this clause, it is advisable to draw a line through it.) In the absence of my ability to give directions regarding the use of life- sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) and agent as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from this refusal. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. Signed ______________________________________ City, County and State of Residence ________________________________ ________________________________________________________________________ The declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the declarant’s signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of the declarant or codicil thereto, or directly financially responsible for the declarant’s medical care. Witness ______________________________________________________________ Witness ______________________________________________________________ PRINT NAME, ADDRESS AND TELEPHONE NUMBER OF PROXY (OPTIONAL) DATE AND SIGN THE DOCUMENT AND PRINT YOUR ADDRESS WITNESSING PROCEDURE ———— YOUR WITNESSES SIGN HERE © 2000 PARTNERSHIP FOR CARING, INC. WYOMING DECLARATION — PAGE 2 OF 2 Courtesy of Partnership for Caring, Inc. 6/96 1620 Eye Street, NW, Suite 202, Washington, DC 20006 800-989-9455