Successor Agents Certification And Acceptance Of Authority (Health Care PoA)

State of IllinoisIllinois Department of Public Health 026//,12,60000357$78725<000035+2570000232500000332:(50002)00001677251(<000)25000025($/7+000020$5(001025026032021013r000032026000032020r000021025f021034021f033t023000031021017025021025017032020r000027026035r030000026016000t032032026030025r036000016026030000020rt023032020000013t030r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t032000t030r000032020r000032020021025017031000021000035t025032000024036000020rt023032020000013t030r000t017r025032000032026000022025026035b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r002,,0030252:000,03257$17000,6000,700072000<2800072000$92,'0003$,1000$1'00068))(5,1*r002,,,003026)000<28000+$'00072000&+226(004000,6000,7000025(000,03257$1700072000<2800072000/,9(000$6000/21*000$60003266,%/(0040002500072000$92,'000352/21*('00068))(5,1*00025000',6$%,/,7<r002,9003 28/'000<280005$7+(5000%(000$7000+20(00025000,1000$000+263,7$/000)250007+(000/$67000'$<600025000:((.60002)000<285000/,)(r00290030212000<28000+$9(0005(/,*,28600400063,5,78$/00400025000&8/785$/000%(/,()60007+$7000<28000:$17000<285000$*(17000$1'00027+(5600072000&216,'(5r0029,0030212000<28000:,6+000720000$.(000$0006,*1,),&$17000&2175,%87,21000720000(',&$/0006&,(1&(000$)7(5000<285000'($7+0007+528*+00025*$100025000:+2/(000%2'<000'21$7,21r0029,,0030212000<28000+$9(000$1000(;,67,1*000$'9$1&('000',5(&7,9(00400068&+000$6000$000/,9,1*000:,//0040007+$7000&217$,16000<28500063(&,),&000:,6+(6000$%287000+($/7+000&$5(0007+$7000,621/<000'(/$<,1*000<285000'($7+r000026)000<28000+$9(000$127+(5000$'9$1&(000',5(&7,9(0040000$.(000685(00072000',6&866000:,7+000<285000$*(170007+(000',5(&7,9(000$1'0007+(75($70(17000'(&,6,216000&217$,1('000:,7+,10007+$7000287/,1(000<28500035()(5(1&(6006000030$.(000685(0007+$7000<285000$*(17000$*5((600072000+21250007+(000:,6+(6000(;00535(66('000,1000<285000$'9$1&(000',5(&7,9(006000035020t032000022021025f000026016000fr013021031021026025031000013t025000024036000t017r025032000024t022rb026)0007+(5(000,6000(9(5000$0003(5,2'0002)0007,0(000:+(1000<2850003+<6,&,$1000'(7(50,1(60007+$7000<28000&$11270000$.(000<2850002:1000+($/7+000&$5(000'(&,6,21600400025000,)000<28000'2000127:$17000720000$.(000<2850002:1000'(&,6,216004000620(0002)0007+(000$&7,216000<285000$*(17000&28/'0007$.(000$5(00072013002,0037$/.000:,7+0003+<6,&,$16000$1'00027+(5000+($/7+000&$5(0003529,'(56000$%287000<285000&21',7,21006002,,0036((0000(',&$/0005(&25'6000$1'000$33529(000:+2000(/6(000&$10006((0007+(0006002,,,003*,9(0003(50,66,21000)250000(',&$/0007(6760040000(',&,1(6004000685*(5<0040002500027+(500075($70(176006002,9003&+226(000:+(5(000<280005(&(,9(000&$5(000$1'000:+,&+0003+<6,&,$16000$1'00027+(560003529,'(000,7006 American LegalNet, Inc. www.FormsWorkFlow.com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f000021000013020026026031r000032026000nr000024036000020rt023032020000013t030r000t017r025032b%22285000$*(17000:,//000+$9(0007+(0005(63216,%,/,7<000720000$.(0000(',&$/00075($70(17000'(&,6,216004000(9(1000,)00027+(50003(23/(000&/26(00072000<280000,*+700085*(000$000',))(5(17000'(005&,6,21006000036+(0006(/(&7,210002)000<285000$*(170006+28/'000%(000'21(000&$5()8//<004000$6000+(000250006+(000:,//000+$9(0008/7,0$7(000'(&,6,210050$.,1*000$87+25,7<000)25000<28500075($70(17'(&,6,21600021&(000<28000$5(00012000/21*(5000$%/(0007200092,&(000<28500035()(5(1&(6006000020+226(000$000)$0,/<0000(0%(5004000)5,(1'0040002500027+(50003(5621000:+2013002,003,6000$7000/($67000bn000<($560002/'f002,,003.12:6000<28000:(//f002,,,003<280007586700072000'2000:+$7000,6000%(67000)25000<28000$1'000,6000:,//,1*00072000&$55<000287000<285000:,6+(6004000(9(1000,)000+(000250006+(0000$<000127000$*5((000:,7+000<285000:,6+(6f002,9003:28/'000%(000&20)257$%/(0007$/.,1*000:,7+000$1'00048(67,21,1*000<2850003+<6,&,$16000$1'00027+(5000+($/7+000&$5(0003529,'(56f0029003:28/'000127000%(000722000836(700072000&$55<000287000<285000:,6+(6000,)000<28000%(&$0(0009(5<0006,&.f000$1'0029,003&$1000%(0007+(5(000)25000<28000:+(1000<280001(('000,7000$1'000,6000:,//,1*00072000$&&(370007+,6000,03257$1700052/(006000035020t032000021016000024036000t017r025032000021031000025026032000t034t021023tn023r026030000021031000033025035021023023021025017000032026000024t022r000fr013021031021026025031000016026030000024rb026)0007+(0003(5621000:+2000,6000<285000),567000&+2,&(000,600081$%/(00072000&$55<0002870007+,600052/(0040007+(10007+(0006(&21'000$*(17000<28000&+26(000:,//0000$.(0007+(000'(&,6,216f000,)000<2856(&21'000$*(17000,6000127000$9$,/$%/(0040007+(10007+(0007+,5'000$*(17000<28000&+26(000:,//0000$.(0007+(000'(&,6,216006000036+(0006(&21'000$1'0007+,