Kentucky Advance Directive

Information you will need

• Name a Surrogate
• Surrogate Name
• Successor Surrogate Name
• Life Prolonging Treatment
• Nourishment and Fluids
• Surrogate Determination
• Specified Organs
• Any Organs, Tissues, and Eye/Corneas
• Organs
• Tissues
• Corneas
• Eyes
• Donation Description
• Grantor Signing Day
• Grantor Signing Month
• Grantor Signing Year
• Grantor Name
• First Witness Address
• Second Witness Address
• Grantor Address
• Grantor DOB
• Notary Only: County
• Notary Only: Month
• Notary Only: Year

…and 16 more fields in the PDF.

Completed by the grantor and the employee.

The form includes 4 signature lines, a notary acknowledgment, a witness section.