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Ephone Numbers: as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if I become unable to make my own health care decisions. (2) Optional: Alternate If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I hereby appoint: Alternate’s Name: Alternate’s Home Address: Alternate’s Telephone Numbers: (3) Unless I revoke it, this proxy shall remain.
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