DURABLE POWER OF ATTORNEY FOR HEALTH CARE

(Missouri Revised Statues 404.800 to 404.872)

1) I, ________________________________, fill out this document to set forth my treatment instructions
and to appoint an attorney in fact in case of my incapacity.

NO BLOOD TRANSFUSIONS
2) I am one of Jehovahs Witnesses, and I direct that NO TRANSFUSIONS of whole blood, red cells, white
cells, platelets or plasma be given me under any circumstrances, even if health-care providers believe
that such are necessary to preserve my life.
3) Regarding minor fractions of blood:
(a) ___ I REFUSE ALL
(b) ___ I REFUSE ALL EXCEPT:
(c) ___ I may be willing to accept some minor blood fractions, but the details will have to be discussed
with me or with my attorney in fact in case of my incapacity.
4) Regarding medical procedures involving the use of my own blood, except diagnostic procedures, such
as blood samples for testing:
(a) ___ I REFUSE ALL
(b) ___ I REFUS ALL EXCEPT:
(c) ___ I may be willing to accept some minor blood fractions, but the details will have to be discussed
with me or with my attorney in fact in case of my incapacity.
5) Regarding end of life matters:
(a) ___ I do not want my life to be prolonged if, to a reasonable degree of medical certainty, my
situation is hopeless.
(b) ___ I want my life to be prolonged as long as possible within the limits of generally accepted
medical standards, even if this means that I might be kep alive on machines for years.
6) Regarding other health-care instructions (such as current medications, allergies and medical problems)
(a) ___ I am allergic to:
(b) ___ I take the following medications: ___________________________________________________
__________________________________________________________________________________
7) I give no one (including my attorney in fact) any authority to disregard or override my instructions set
forth herein. Family members, relatives, or friends may disagree with me, but any such disagreement
does not diminish the strength or substance of my refusal of blood or other instructions.
8) Apart from the matters covered above, I appoint the person named herein as my attorney in fact to
make healthcare decisions for me. I give my attorney in fact full power and authroity to consent to or to
refuse treatment (including the authority to direct a health-care provider to provide, withhold, or
withdraw artificially supplied nutrition and hydration) on my behalf, to consult with my doctors and
receive copies of my medical records, and to take legal action to ensure that my wishes are honored. If
my first appointed attorney is in fact unavailable, unable or unwilling to serve, I appoiont an alternate
attorney in fact herein to serve with the same power and authority.

ATTORNEY IN FACT:

_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

ALTERNATE ATTORNEY IN FACT:

_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

9) This is a Durable Power of Attorney for Health Care and the authority of my attorney in fact, when
effective shall not terminate or be void or voidable if I am or become disabled or incapacitated or in the
event of later uncertainty as to whether I am dead or alive.
In witness whereof, I sign my name to this document on the date indicated below:
______________________________________________________

_________________

Signature

Date

____________________________________________________________________________
Address

STATEMENT OF WITNESSES: The principal (the person who signed above) voluntarily signed this
document in my presense. He/she appears to be of sound mind and free from duress, fraud or undue
influence. I am 18 years of age or older. I am not the person who signed this document above on behalf
of and at the direction of the principal. I am not the attorney in fact or alternate attorney in fact
appointed in this document.
______________________________________________________
Signature of Witness

_________________
Date

____________________________________________________________________________
Address

______________________________________________________
Signature of Witness

_________________
Date

____________________________________________________________________________
Address

AND NOTARIZED BY:

STATE OF _______________
COUNTY OF _____________
On this __ day of __________________, 20____ before me personally appeared ___________________,
to me known to be the person described in and who executed the foregoing Durable Power of Attorney
for Health Care, and acknowledged to me that she executed the same as her free act and deed. In
witness whereof, I herunto set my hand and official seal.
My Commission expires: ___________

Notary Public: ___________________________________