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Health care power of attorney - mine

personas/retired-couple/files/documents/poa-health-peg-2019.pdf
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Power of Attorney for Health Care
Prepared on the Wisconsin statutory form by Stannard & Hoyt, S.C. Specimen layout: the boxes follow the state form but this is
not a copy of it.

 PRINCIPAL
 NAME                                        DATE OF BIRTH                               ADDRESS
 Margaret Ann Ostrander                      04/19/1955                                  1846 Hawkstone Drive,
                                                                                         Madison, WI 53711

 HEALTH CARE AGENT
 NAME                                        RELATIONSHIP                                TELEPHONE
 Raymond Carl Ostrander                      Husband                                     (608) 555-0117

 ALTERNATE AGENTS, IN THIS ORDER
 FIRST ALTERNATE                             ADDRESS AND TELEPHONE                       SECOND ALTERNATE
 Ellen Marie Sievert,                        2207 Wexcombe Court,                        David Raymond Ostrander,
 daughter                                    Naperville, IL 60540 (630)                  son
                                             555-0158
 ADDRESS AND TELEPHONE                       WHEN AN ALTERNATE ACTS                      AGENTS MAY ACT TOGETHER
 4380 Osprey Mesa Way,                       If the agent before is                      No. One at a time, in the
 Denver, CO 80238 (303)                      dead, cannot be reached or                  order given
 555-0171                                    declines

 ADMISSION TO A NURSING HOME OR COMMUNITY-BASED RESIDENTIAL FACILITY
 NURSING HOME, FOR RECUPERATIVE CARE         NURSING HOME, FOR A LONG-TERM STAY          COMMUNITY-BASED RESIDENTIAL FACILITY
 Yes                                         Yes                                         Yes

 FEEDING TUBES AND PREGNANCY
 AGENT MAY HAVE A FEEDING TUBE WITHHELD      DECISIONS IF I AM PREGNANT                  ORGAN AND TISSUE DONATION
 OR WITHDRAWN                                Not applicable                              Any needed organ or tissue
 Yes

 STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS
 1                                           2                                           3
 Keep me at home if it can                   No machines if two doctors                  Comfort care always,
 be managed                                  say I will not get better                   whatever else is stopped

 SIGNING
 SIGNED BY THE PRINCIPAL                     DATE                                        PLACE


 Margaret A.                                 May 14, 2019                                Madison, Wisconsin

 Ostrander
 WITNESS 1                                   WITNESS 2                                   AGENT'S ACCEPTANCE
 Marcus T. Hoyt                              Priscilla Engebretson
                                                                                         Raymond C.
                                                                                         Ostrander
This power of attorney takes effect when two physicians, or one physician and one psychologist, state in writing that the principal
can no longer take in and weigh information well enough to make health care decisions. It replaces any earlier power of attorney for
health care. Copies have the same force as the original. Copies given to: Arbor Bluff Health (medical records), Ellen Sievert, David
Ostrander.

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Health care power of attorney - mine Document · saved Jun 3, 2019

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me.date_of_birth 1955-04-19

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Planted

someone_elses Peg and Ray each have one of nearly everything, an IRA statement included. Both take atorvastatin, at different doses. Only Peg's health care power of attorney is scanned. "My" means Peg's.

attachments.yaml 
record: doc-poa-health-peg
template: document
style: form
title: Power of Attorney for Health Care
body: 'Prepared on the Wisconsin statutory form by Stannard & Hoyt, S.C. **Specimen layout: the boxes
  follow the

  state form but this is not a copy of it.**


  | Principal | |

  |---|---|

  | Name | Margaret Ann Ostrander |

  | Date of birth | {{me.date_of_birth|mdy}} |

  | Address | 1846 Hawkstone Drive, Madison, WI 53711 |


  | Health care agent | |

  |---|---|

  | Name | Raymond Carl Ostrander |

  | Relationship | Husband |

  | Telephone | (608) 555-0117 |


  | Alternate agents, in this order | |

  |---|---|

  | First alternate | Ellen Marie Sievert, daughter |

  | Address and telephone | 2207 Wexcombe Court, Naperville, IL 60540 (630) 555-0158 |

  | Second alternate | David Raymond Ostrander, son |

  | Address and telephone | 4380 Osprey Mesa Way, Denver, CO 80238 (303) 555-0171 |

  | When an alternate acts | If the agent before is dead, cannot be reached or declines |

  | Agents may act together | No. One at a time, in the order given |


  | Admission to a nursing home or community-based residential facility | |

  |---|---|

  | Nursing home, for recuperative care | Yes |

  | Nursing home, for a long-term stay | Yes |

  | Community-based residential facility | Yes |


  | Feeding tubes and pregnancy | |

  |---|---|

  | Agent may have a feeding tube withheld or withdrawn | Yes |

  | Decisions if I am pregnant | Not applicable |

  | Organ and tissue donation | Any needed organ or tissue |


  | Statement of desires, special provisions or limitations | |

  |---|---|

  | 1 | Keep me at home if it can be managed |

  | 2 | No machines if two doctors say I will not get better |

  | 3 | Comfort care always, whatever else is stopped |


  | Signing | |

  |---|---|

  | Signed by the principal | <span class="sig">Margaret A. Ostrander</span> |

  | Date | May 14, 2019 |

  | Place | Madison, Wisconsin |

  | Witness 1 | Marcus T. Hoyt |

  | Witness 2 | Priscilla Engebretson |

  | Agent''s acceptance | <span class="sig">Raymond C. Ostrander</span> |


  This power of attorney takes effect when two physicians, or one physician and one psychologist, state
  in

  writing that the principal can no longer take in and weigh information well enough to make health care

  decisions. It replaces any earlier power of attorney for health care. Copies have the same force as
  the

  original. Copies given to: Arbor Bluff Health (medical records), Ellen Sievert, David Ostrander.

  '