Michael Andrew Harding
(Printed Name)
06/09/1968
(Date of Birth)
Health Care Surrogate Designation
By checking and initialing the line below, I specifically:
Designate Natalie Beck as my health care surrogate(s) to make health care decisions for me in accordance with this directive when I no longer have decisional capacity. If Natalie Beck refuses or is not able to act for me, I designate Thomas Harding as my health care surrogate(s).
Box Checked: Box Checked
Initials: MAH
Any prior designation is revoked.
Living Will Directive
If I do not designate a surrogate, the following are my directions to the attending physician. If I have designated a surrogate, my surrogate shall comply with my wishes as indicated below. By checking and initialing the lines below, I specifically:
Life Prolonging Treatment
Box Checked: True
Initials:
Nourishment and/or Fluids
Box Checked: True
Initials:
Surrogate Determination of Best Interest
As designated on the previous page, to withhold or withdraw artificially provided nourishment or fluids, or other treatment if the surrogate determines that the withholding or withdrawing is in my best interest; but I do not mandate that withholding or withdrawing.
Box Checked: True
Initials: MAH
Organ/Tissue/Eye Donation
I certify that I am eighteen (18) years of age or older and of sound mind, and that upon my death, I hereby give:
I do not wish to donate any organs
Box Checked: True
Initials: MAH
Declaration and Signature Block
In the absence of my ability to give directions regarding the use of life-prolonging treatment and artificially provided nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family, and any surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of the refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no force or effect during the course of my pregnancy.
I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Signed on this 15 day of August, 2024.
Grantor Signature
Michael A Harding
Grantor Address
PO Box 266 Yellow Springs OH 45387
Witness Signature
Natalie Beck
Witness Address
PO Box 266 Yellow Springs OH 45387
Witness Signature
Franki Barker
Witness Address
2871 Greentree Xenia OH 45385
NOTARY BLOCK
COMMONWEALTH OF KENTUCKY, County
Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18) years of age or older, and acknowledged that he/she voluntarily dated and signed this writing or directed it to be signed and dated as above.
Done this day of , 20
Signature of Notary Public
Date commission expires
Michael Andrew Harding
(Printed Name)
06/09/1968
(Date of Birth)
Health Care Surrogate Designation
By checking and initialing the line below, I specifically:
Designate Natalie Beck as my health care surrogate(s) to make health care decisions for me in accordance with this directive when I no longer have decisional capacity. If Natalie Beck refuses or is not able to act for me, I designate as my health care surrogate(s).
Box Checked: Box Checked
Initials: MAH
Any prior designation is revoked.
Living Will Directive
If I do not designate a surrogate, the following are my directions to the attending physician. If I have designated a surrogate, my surrogate shall comply with my wishes as indicated below. By checking and initialing the lines below, I specifically:
Life Prolonging Treatment
Box Checked: True
Initials:
Nourishment and/or Fluids
Box Checked: True
Initials:
Surrogate Determination of Best Interest
As designated on the previous page, to withhold or withdraw artificially provided nourishment or fluids, or other treatment if the surrogate determines that the withholding or withdrawing is in my best interest; but I do not mandate that withholding or withdrawing.
Box Checked: True
Initials: MAH
Organ/Tissue/Eye Donation
I certify that I am eighteen (18) years of age or older and of sound mind, and that upon my death, I hereby give:
I wish to specify among organs, tissues, eyes, and corneas (select specifically below)
Corneas, Eyes
Box Checked: True
Initials: MAH
Declaration and Signature Block
In the absence of my ability to give directions regarding the use of life-prolonging treatment and artificially provided nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family, and any surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of the refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no force or effect during the course of my pregnancy.
I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Signed on this 19 day of August, 2024.
Grantor Signature
Michael Andrew Harding
Grantor Address
PO Box 266, Yellow Springs, OH 45387
Witness Signature
Witness 1
Witness Address
somewhere
Witness Signature
Witness 2
Witness Address
somewere else
NOTARY BLOCK
COMMONWEALTH OF KENTUCKY, County
Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18) years of age or older, and acknowledged that he/she voluntarily dated and signed this writing or directed it to be signed and dated as above.
Done this day of , 20
Signature of Notary Public
Date commission expires
Megan R. Holt
(Printed Name)
April 7, 1981
(Date of Birth)
Health Care Surrogate Designation
By checking and initialing the line below, I specifically:
Designate as my health care surrogate(s) to make health care decisions for me in accordance with this directive when I no longer have decisional capacity. If refuses or is not able to act for me, I designate Joshua M. Holt as my health care surrogate(s).
Box Checked:
Initials:
Any prior designation is revoked.
Living Will Directive
If I do not designate a surrogate, the following are my directions to the attending physician. If I have designated a surrogate, my surrogate shall comply with my wishes as indicated below. By checking and initialing the lines below, I specifically:
Life Prolonging Treatment
Box Checked: True
Initials:
Nourishment and/or Fluids
Box Checked: True
Initials:
Surrogate Determination of Best Interest
DO NOT authorize my surrogate to withhold or withdraw artificially provided nourishment or fluids.
Box Checked: True
Initials: MRH
Organ/Tissue/Eye Donation
I certify that I am eighteen (18) years of age or older and of sound mind, and that upon my death, I hereby give:
I do not wish to donate any organs
Box Checked: True
Initials: MRH
Declaration and Signature Block
In the absence of my ability to give directions regarding the use of life-prolonging treatment and artificially provided nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family, and any surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of the refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no force or effect during the course of my pregnancy.
I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Signed on this 24 day of August, 2024.
Grantor Signature
Megan R. Holt
Grantor Address
508 South Dogwood, Berea, Kentucky 40403
Witness Signature
Joshua M. Holt
Witness Address
508 South Dogwood, Berea, Kentucky 40403
Witness Signature
Carla R. Jordan
Witness Address
Peaster, Texas
NOTARY BLOCK
COMMONWEALTH OF KENTUCKY, County
Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18) years of age or older, and acknowledged that he/she voluntarily dated and signed this writing or directed it to be signed and dated as above.
Done this day of , 20
Signature of Notary Public
Date commission expires