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ADVANCE DIRECTIVE of ____________________
I, ____________________ (the "Donor"), of ______________________________________________________________, New Zealand, being of sound mind and at least 18 years of age, make this Advance Directive, fully understanding the consequences of my action in doing so. I intend this Advance Directive to be read by my health care providers, family, whanau and friends as a true reflection of my wishes and instructions should I lack Capacity and be unable to communicate such wishes and instructions.
SignatureSigned by me under hand and seal in the presence of my witness in the country of New Zealand, this ________ day of ________________, ________.
______________________________________(Signature of the Donor)
______________________________________(Signature of witness)
______________________________________(Printed name of witness)
__________________________________________________________________________________________________________________(Address of witness)
Record of CopiesRecord of people and institutions to whom I have given a copy of this Advance Directive:
1.
________________________________________
Date: ____________________
2.
3.
4.
5.
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