Wyoming Advance Directive

Information you will need

• Date
• Page Completion Initials
• Alternate Agent Name
• Agent Name
• Agent Address
• Agent City / State / ZIP Code
• Alternate Agent Address
• Alternate Agent City / State / ZIP Code
• Agent Phone Numbers
• Alternate Agent Phone Numbers
• Agent Authority
• Effective Commencement
• Primary Physician and Health Care Provider
• Primary Physician
• Execution of Form
• End of life Decisions
• Prolong Life
• Do Not Prolong Life
• Artificial Nutrition
• Artificial Hydration
• Pain Relief
• Treatment for Pain Relief
• Other Wishes
• Body Donation

…and 29 more fields in the PDF.

Completed by the agent and the provider and the principal.

The form includes 2 signature lines, a notary acknowledgment, a witness section.

The document text refers to the laws of Wyoming.