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R LAWYER DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS (Medical Power of Attorney) , I (the "Principal") hereby designate (Type or Print) First Name Last Name City (Type or Print) Street Address State Zip Code as my attorney in fact (my agent) and give to my agent the power to make health care decisions for me. This power exists only when I am unable, in the judgment of my attending physician, to make those health care decisions. The attorney in fact must act consistently with my d.

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