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Special Power of Attorney for Medical Authorization

 

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17. Life Inssurance Trust Declaration

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21. Power of Attorney – General

22. Power of Attorney – Special

23. Power of Attorney – Medical Authorization

24. Promissory Note

25. Notice of Revocation of Power of Attorney

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SPECIAL POWER OF ATTORNEY FOR MEDICAL AUTHORIZATION

I, ________(1)__________, of ________(2)____________, hereby appoint __________(3)____________, of _________(4)___________, as my attorney in fact to do any and all of the following:

1. Make any and all decisions and authorize all procedures that _____(5)____ may deem necessary regarding the medical treatment of my children, _____(6)_____ and/or ______(7)______.

The rights, powers, and authority of my attorney in fact to exercise any and all of the rights and powers herein granted shall commence and be in full force and effect on ____________(8)_______, 20__(9)_, and shall remain in full force and effect until ___________(10)_______________ or unless specifically extended or rescinded earlier by either party.

Dated _______(11)____________, 20_(12)__.

____________(13)_______________

STATE OF _________(14)___________

COUNTY OF ________(15)__________

BEFORE ME, the undersigned authority, on this _(16)_ day of _______(17)_______, 20_(18)_, personally appeared _______(19)_______________ to me well known to be the person described in and who signed the Foregoing, and acknowledged to me that he executed the same freely and voluntarily for the uses and purposes therein expressed.

WITNESS my hand and official seal the date aforesaid.

_____________(20)____________

NOTARY PUBLIC

My Commission Expires:__(21)__

 

 


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