SAMPLE Advance Directive Form

Information you will need

• onger able to recognize family or friends
• total dependence on others for daily care
• Other
• Initial and check only one
• under any circumstances
• Cardiopulmonary Resuscitation (CPR)
• Dialysis
• devisees and personal representatives.
• State of
• County of
• Signed and sworn to me on the
• day of
• hereby certify that the Principal
• Given under my hand this
• Notary Public Signature
• Printed Name
• My commission expires

Completed by the agent and the principal and the provider.

The form includes 1 signature line, a notary acknowledgment, a witness section.

The document text refers to the laws of Vermont.