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Signature....
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Witness No. 2:
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(print) Name.... Date....
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Signature....
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STATEMENT OF HEALTH CARE AGENT
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AND ALTERNATE HEALTH CARE AGENT
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I understand that.... (name of principal) has designated me to be his or her
12health care agent or alternate health care agent if he or she is ever found to have
13incapacity and unable to make health care decisions himself or herself. .... (name
14of principal) has discussed his or her desires regarding health care decisions with me.
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Agent's signature....
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Address....
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Alternate's signature....
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Address....
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Failure to execute a power of attorney for health care document under chapter
20155 of the Wisconsin Statutes creates no presumption about the intent of any
21individual with regard to his or her health care decisions.
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This power of attorney for health care is executed as provided in chapter 155
23of the Wisconsin Statutes.
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24ANATOMICAL GIFTS (optional)
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25Upon my death:
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1.... I wish to donate only the following organs or parts: .... (specify the organs
2or parts).
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3.... I wish to donate any needed organ or part.
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4.... I wish to donate my body for anatomical study if needed.
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5.... I refuse to make an anatomical gift.
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6Failing to check any of the lines immediately above creates no presumption
7about my desire to make or refuse to make an anatomical gift.
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8Signature.... Date....
AB582, s. 3
9Section
3. 157.06 (2) (f) 1m. of the statutes is created to read:
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157.06
(2) (f) 1m. Signing a new document of gift. Signing a new document of
11gift revokes any previously signed document of gift.
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12Section
4. 157.06 (2) (f) 6. of the statutes is created to read:
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157.06
(2) (f) 6. Revoking the provision of a power of attorney for health care
14instrument that makes an anatomical gift or revoking that power of attorney for
15health care instrument.
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16Section
5. 157.06 (3) (a) 7. of the statutes is created to read:
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157.06
(3) (a) 7. A health care agent, as defined in s. 155.01 (4), for the decedent
18at the time of death.
