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Get ADVANCE HEALTH CARE DIRECTIVE MY NAME IS MY ADDRESS IS: (Address) (City) (State) (Zip Code) PART 1

Wing individual as my agent to make health care decisions for me: (Name of individual you choose as agent) (Address) City) (State) (Zip code) (Home phone) (Work phone) (E-Mail or other means of contact) OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health care decision for me, I designate as my first alternate agent: (Name of individual you choose as first alternate agent) (Address) (Home phone) (City) (Work phone) (State).

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