Nevada Advance Directive Form

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A Nevada advance directive is a document that allows a person to create a power of attorney for health care and declare a living will. The document lets an agent be designated to make health care decisions on behalf of someone else and to outline their preferred treatment options. An advance directive must be signed with at least two (2) witnesses or a notary public. After completing, it may only be used when the patient becomes incapacitated or not able to make clear decisions for themselves.

Table of Contents

Laws

Statutes

Signing Requirements (NRS 162A.790(2), NRS 449A.433(1)) – Two (2) witnesses or a notary public. A detailed list of persons ineligible to act as witnesses can be found under subsection 3 of NRS 162A.790.

State Definition (NRS 449A.703) – “Advance directive” means an advance directive for health care. The term includes:

  1. A declaration governing the withholding or withdrawal of life-sustaining treatment as set forth in NRS 449A.400 to 449A.481, inclusive;
  2. A durable power of attorney for health care as set forth in NRS 162A.700 to 162A.870, inclusive;
  3. An advance directive for psychiatric care as set forth in NRS 449A.600 to 449A.645, inclusive;
  4. A do-not-resuscitate order as defined in NRS 450B.420; and
  5. A Provider Order for Life-Sustaining Treatment form as defined in NRS 449A.542.

Versions (3)


AARP

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Nevada Center for Ethics and Policy

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Spanish (Español) Version

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Registry

To register an advance directive for free an individual can send a signed copy along with the attached Registration Agreement (Form SPLB-0001) to the following:

  • Mailing Address: Nevada Lockbox, c/o Nevada Secretary of State, 2250 Las Vegas Blvd. North, Suite 400 North Las Vegas, NV 89030
  • Fax Number: (775) 684-7177

After approximately ten (10) business days, a wallet card will be sent to the declarant with instructions on how to access the document. If for any reason a change is needed to be made to the directive, the declarant can file the Authorization to Change (Form SPLB-0002) in the same manner as above.

How to Write

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Article I Designation Of Health Care Agent

(1) Nevada Principal Name. The Principal issuing this Nevada document should be named as the Nevada Patient issuing his or her appointment of a Nevada Health Care Agent or Nevada Medical Attorney-in-Fact.

(2) Name Of Nevada Health Care Agent. The name of the Medical Attorney-in-Fact that the Nevada Principal wishes to appoint is required by the declaration statement made.

(3) Address Of Nevada Health Care Agent. After the name of the Nevada Health Care Agent or Medical Attorney-in-Fact has been dispensed, produce his or her mailing address.

(4) Phone And Work Of Nevada Health Care Agent.

Article 4. Special Provisions And Limitations

(5) Principal Initials Of Authorization. The Nevada Principal should initial the bottom of the first page before continuing. This will serve as proof that he or she has read this page to comprehension and provided the information above.

(6) Impose Limitations And Instructions. The scope of powers this document grants to the Nevada Medical Attorney-in-Fact will be broad and far-reaching (by default). If the Nevada Principal, however, has strong feelings regarding any treatment options or Health Care Facilities, then he or she should include a set of instructions or limitations to the decision-making powers being granted. A section has been set aside for this purpose and will allow for an attachment with this information to be cited by title.

Article 5. Duration

(7) Termination Date. This appointment of a Nevada Medical Attorney-in-Fact can be left to continue indefinitely or until the Nevada Principal revokes it or it can be set with a specific date of termination. If this paperwork’s effect should cease naturally as of a certain date, then record the desired termination date to the fifth article.

Article 6. Statement Of Desires

(8) Desire For Life Prolonging Treatment. Several statements meant to instruct attending Nevada Physicians on the Principal’s desired health care have been presented. Each one that matches a treatment directive the Nevada Principal wishes to adopt as his or her own should be initialed by the Principal. Thus, if the Nevada Principal wishes his or her life extended through any life-prolonging treatment deemed lawful and appropriate, then he or she should initial the box next to Statement 1.

(9) Denying Treatment When Permanently Unconscious. If the Nevada Principal is declared as being in a permanent coma with no hope of waking up or recovery and does not wish life-prolonging treatment administered when in this condition, then Statement 2 should be initialed.

(10) Refusing Life-Prolonging Treatment When Terminal. The Nevada Principal can address the topic of life-prolonging treatment when he or she has a (medical) condition that has no cure or treatment. If the Nevada Principal intends to deny the administration of life-prolonging treatment when no hope of recovery can be had then Statement 3 should be initialed.

(11) Withholding/Withdrawal Of Artificial Nutrition And Hydration. Now, if the Nevada Principal has been incapacitated, suffering from a terminal (medical) condition, and/or is in a permanent coma then his or her decision on the administration of nourishment and water artificially (for example, through a tube or an I.V.) will be needed. If Statement 4 is initialed, then the Nevada Principal will be informing Doctors in this state that he or she approves of the artificial delivery of food and water when he or she cannot intake nutrients or liquids naturally or with hand-assisted feedings. Note that if Statement 4 is not initialed, then the Nevada Principal will not be delivering consent to receive nutrients and liquids artificially when needed to prevent starvation or dehydration.

(12) Recovery And Longevity Directive. If the chances for recovery from a permanent coma or a diagnosis of a fatal (medical) condition are slim, will result in a painful recovery or only a partial recovery, then it will be up to the Principal to decide on the treatments involved. If the Nevada Principal is unconscious, then Statement 5 can be used to inform Nevada Physicians that the Medical Attorney-in-Fact should make this decision after weighing the options while making quality of life a priority. 

Memorial Service

(13) Funeral Instructions. While this paperwork deals specifically with the Nevada Principal’s health care preferences and the Party who should represent them, an area has been devoted to accept his or her instructions for a memorial service (where those close to the Principal may remember and honor his or her life). This is an optional area so it may be left blank if the Nevada Principal has no such preferences or instructions.

(14) Other Wishes. The Nevada Principal may have specific near-death or post-death directions. This section can be used to discuss Nevada Principal preferences ranging from organ donations and anatomical gifts made after death to hospice care preferences to be put into effect when near death. The Nevada Principal can be as specific in his or her wishes as needed even if he or she must continue this section in a separate document that is then attached to this one (and appropriately titled).

Article 7. Designation Of Alternate Attorney-in-Fact

(15) First Alternative Attorney-in-Fact. Some precautions can be taken through this document to handle a situation where the Nevada Principal’s Medical Attorney-in-Fact is not able to fill this role whether because he or she cannot (i.e., revoked, traveling, etc.) or will not. To make sure the Nevada Principal can still have an approved Agent to represent him or her, a First Alternative Attorney-in-Fact can be named to successively step into this role if it becomes empty while the Nevada Principal is incapacitated and in need of a Health care Agent or Medical Attorney-in-Fact. To appoint a First Alternative Attorney-in-Fact, record his or her name.

(16) First Attorney-in-Fact Contact Information. The First Alternative Attorney-in-Fact’s address, home or cell phone number, and work number should be provided for the easy reference of future Reviewer.

(17) Second Alternative Attorney-in-Fact. A second precaution that can take is the appointment of a Second Alternative Attorney-in-Fact. This Party will be able to assume the Nevada Medical Attorney-in-Fact appointment when the previous two choices leave this role empty. This will enable the Nevada Principal to continue having his or her medical preferences represented to attending Physicians in this state through the principal powers granted this document appoints to this position. Produce the full name of the intended Second Alternative Attorney-in-Fact to make this designation.

(18) Second Alternative Attorney-in-Fact Contact Details. Produce the current address and phone numbers where the Second Alternative Attorney-in-Fact can be reached to the blank lines requesting this information.

Signature Execution

(19) Signature Date. This Nevada Directive must bear the approval of the Principal or Patient it concerns. he or she must sign this document before two Witnesses or while a Notary Public is in attendance. When he or she is ready, this process must begin with a production of the current date.

(20) City And State Of Signature.

(21) Nevada Principal Signature. The signature of the Nevada Principal is required on the final line of the signature area of his or her own free will and a clear understanding of this document’s content

(22) Nevada Principal Printed Name.

(23) Address Of The Nevada Principal.

(24) Nevada Principal’s Phone And Work Number.

(25) Social Security Of Nevada Principal.

Article 10 Certificate Of Acknowledgment Of Notary Public

(27) Nevada Principal Signature Notarization. A recommended way of proving that the Nevada Principal signed this document while cognizant and willing through the notarization process. The Notary Public will serve as Testimonial Party by watching the Nevada Principal sign this form then submitting this document to the notarization process.

Article 11. Statement Of Witness

(28) Witness Number One’s Signature. Two Witnesses are expected to sign this document if the Nevada Principal has not obtained a Notary Public. Witness Number One will need to read the statement made then sign his or her name as a confirmation that it is a true and accurate testimonial.

(29) Witness Number One’s Name And Address. The full printed name and address of Witness Number 1 should be supplied by this Party once he or she signs this document. 

(30) Witness Number One’s Signature Date. The calendar date when Witness Number One signs his or her name should be documented with the provided signature.

(31) Witness Number Two’s Signature. In the absence of a notarization, Witness Number Two will also be called upon to sign his or her name to the confirmation statement defining the Nevada Principal’s act of signing.

(32) Witness Number Two’s Name And Address. Witness Number Two must dispense his or her printed name and address to this area.

(33) Witness Number Two’s Signature Date. Witness Number Two must produce the current date to accompany his or her signature

Article 12 Declaration Of Witness

(34) Signature Of Witness Number One. An additional declaration must be signed by at least one of the Witnesses above. If Witness Number One can honestly state that he or she is not related to the Nevada Principal (i.e., by blood, by marriage, or through adoption), and does not believe he or she will be entitled to any part of the Nevada Principal’s estate (after death). If Witness Number One can make both such statements, then he or she should sign the first signature line provided.

(35) Printed Name And Residential Address.

(36) Signing Date For Witness Number One. If Witness Number One is able to make the additional declaration, then he or she is expected to date the signature provided.

(37) Witness Number Two’s Signature. If Witness Number 2 can declare that he or she will not be legally entitled to any of the Nevada Principal’s estate and that he or she is not related to the Nevada Principal in any way, then he or she should sign this additional declaration. Witness Number Two can make this testimony whether or not the first Witness has done so.

(38) Witness Two’s Name And Residential Address.

(39) Date Of Witness Two’s Signature.

Declaration Living Will

(40)  Living Will’s Nutrition And Hydration Directive. The second document of this directive is set to inform Nevada Physicians that the Declarant or Patient behind it wishes that all attempts to prolong or extend life through medical treatment cease or be denied when he or she is subjected to a fatal (medical) condition that will lead to death soon. One subject must be addressed directly through this document. That of artificially administered nutrition and hydration. Many terminal conditions will eventually rob the Patient of his or her ability to intake food and water independently or without the hazard of choking. If the Nevada Declarant wishes to approve of having food and water delivered through a tube directly to his or her gastrointestinal tract, directly to the blood through an I.V., or other methods available then the box next to this declaration statement must be initialed. If the Nevada Principal or Declarant wishes to withhold approval for artificially delivered nourishment and water, then this box should be left blank. Nevada Declarant Dated Signature.

(41) Signature Date. The calendar date when the Nevada Declarant signs this directive will be the first date of its effect. He or she must enter this date just before signing his or her name.

(42) Nevada Declarant Signature. The Nevada Declarant should sign this paperwork as two (adult) Witnesses observe.

(43) Address Of Nevada Declarant.

Witness Affirmation

(44) Witnesses’ Signatures And Addresses. Each Witness to the Nevada Declarant’s signature must sign his or her name then present his or her address.

A Letter To My Loved Ones

(45) Request For Quality Of Life. A letter designed specifically to deliver the Nevada Principal or Declarant’s preferences when facing an end-of-life event has been supplied. The first part, which focuses on the requests the Nevada Principal can make to be kept comfortable is presented as a series of statements lettered (A) through (F). Here, by initialing certain the Nevada Principal can request that his or her loved ones do their best to keep the Nevada Principal free of suffering, at a normal body temperature, to be given moisture to the lips and mouth, kept clean (bathed), to be massaged, and that his or her hygiene (i.e., hair, nails, etc.) be maintained. The Nevada Principal can initial any and all requests he or she wishes to make in this section or leave this area unattended.

Nevada Principal’s Requests For Consideration

(46) Visit Consideration. The Nevada Principal can request that his or her loved ones visit him or her during an end-of-life event (even if unconscious), speak about daily topics, and request physical comfort (i.e., holding hands) by initialing the appropriate requests (lettered (A) through (C)) as needed. This second list, much like the first, can be left unapproved or partially approved depending on the Nevada Principal’s wishes.

(47) Spiritual Support. The Nevada Principal can request that his or her religious community is informed of his or her end-of-life event so that prayers and spiritual support should be given by initialing the request labeled (D)

(48) Environment Requests. Requests (E) through (H) enables the Nevada Principal to make specific requests regarding his or her surroundings and environment. Thus, requests to maintain a good or cheerful atmosphere around the Nevada Declarant, to adorn the room with photos of loved ones, to maintain a clean sleeping area and clothes, and/or to be allowed to die at home by selecting the appropriate statement request.

(49) Emotional Support Request. Statement requests lettered (I) through (M) allow the Nevada Principal or Declarant to request activities and circumstances that will promote a positive emotional state. For instance, he or she (the Nevada Principal) can request that favorite shows and sports events be made available to watch, that his or her favorite music be played, and to have readings from his or her religious texts and other sources read. Any statement in this list that is not initialed by the Nevada Principal will be considered unwanted by him or her or of a low priority, while those bearing the Nevada Principal’s initials will be assumed to be direct requests made by him or her.

When Unable To Communicate

(50) Personal Feelings Toward Loved Ones. The third area of this letter provides some numbered statements containing direct communication from the Nevada Principal when he or she cannot speak. The first three of these numbered statements allow the Nevada Principal to convey that he or she loves the letter’s Recipient, wishes to be forgiven for any previous wrongs, and forgives the Recipient for anything in the past. To issue any of these statements in this letter, the Nevada Principal only needs to provide his or her initials to the box on the right of the desired statement.

(51) Personal Feelings On Death. The Nevada Principal can use Statements 4 and 5 to inform his or her loved ones that he or she does not fear death and wants his or her Family Members to recommit or reconnect during the end of his or her life. 

(52) Personal Requests Regarding Dying. Statements 6, 7, and 8 serve to request that the Principal’s loved ones remember him or her before being stricken with a fatal or terminal condition, that this even (of dying) be used for personal growth, and that the Nevada Principal encourages his or her loved ones to seek counseling if the Nevada Principal’s death causes them pain. The Nevada Principal can initial any of these statements with the understanding that each one initialed will be considered a direct message from him or her to the Loved Ones receiving this document.

Nevada Principal Request On Remembrance

(53) How The Nevada Principal Wishes To Be Remembered. The Nevada Principal can request that his or her Loved Ones remember and discuss him or her in a certain way with Friends when asked. The first set of empty lines will accept this request of the Nevada Principal.

(54) Funeral Requests. Any funeral plans or requests of the Nevada Principal should be dispensed directly to this letter to keep his or her  Loved Ones informed.

(55) Memorial Service Requests. Specific requests for how a memorial service for the Nevada Principal should unfold can be made through this document.

(56) Final Nevada Principal Requests. Any remaining topics or requests the Nevada Principal wishes included in this letter should be recorded in the final section.

Closing The Nevada Principal Letter Of Requests

(57) Date. While the letter portion of this package is not a legal document, there should still be a demonstration from the Nevada Principal that it should be taken seriously. This is best achieved with his or her dated signature. This process starts with the Nevada Principal’s report of the current calendar date just before signing this document.

(58) Signature. If possible, the Nevada Principal should sign this letter as proof that it carries his or her direct approval.

(59) Printed Name.

Nevada POLST

Side 1: Medical Orders

(60) Nevada Patient Name. This directive includes the Nevada POLST, which is used to show that a licensed Physician agrees with the Nevada Principal’s treatment preferences and thus, should be considered standing treatment orders. This document is stored in the Nevada Patient (or Declarant) medical records therefore, the first piece of information required is the full name of the Nevada Patient.

(61) Nevada Patient’s Personal Information. The birth date of the Nevada Patient as well as the last four digits of his or her social security number and gender should be documented.

Section A CPR

Select Statement 62 Or Statement 63

(62) Attempt Cardiopulmonary Resuscitation (CPR). The Nevada Patient will likely be unconscious or otherwise unable to communicate his or her health care decisions. This will be especially true if the Nevada Patient’s heart and/or lungs cease to function. When this happens, death is often inevitable. If the Nevada Patient approves of all methods of CPR (i.e., mechanical, electrical, chemical) administered as a response to a cardiopulmonary event, then Section A’s first choice should be selected. 

(63) Allow Natural Death. If the Nevada Patient has decided that CPR or cardiopulmonary resuscitation should not be provided when he or she experiences failure of the heart and/or lungs, then select the second checkbox statement.

Section B Medical Interventions

The Comfort Care Directive

(64) Comfort Measures Only. If the Nevada Patient is unable to communicate his or her level preferred level of care then Physicians in this state will refer to Section B of this paperwork. If he or she prefers that all medical treatments given be assigned the goal of keeping the Patient comfortable, even if this will hasten the Patient’s death then select Statement 1, making sure to include any specific instructions in the space provided.

2. Limited Medical Interventions

(65) Life-Sustaining Antibiotics. The Nevada Patient may wish to declare his or her treatment preferences over antibiotics delivered while he or she is unresponsive or unable to communicate. This preference can be declared by selecting the appropriate directive from Statement 2. In this way, the Nevada Patient can inform Physicians that he or she does not wish to receive antibiotics, allow them to be administered by mouth, or by IV. An area has been supplied to receive additional instructions such as the imposition of a trial period or allowing antibiotics administered only for certain medical conditions.

(66) Artificial Nutrition. This document can be used to inform Nevada Physicians that the Patient issuing this form refuses nutrition and water through a tube, establish the Nevada Patient’s approval of artificially administered nutrition, or refuse artificially delivered nutrition. To do so, select one of these three options from the column on the left. Notice, that an optional space has been provided should additional details be required to fully define the Nevada Principal’s status or requests

(67) The I.V. Fluids Directive. If the Nevada Principal cannot drink water or intake fluids, then he or she will run the risk of dehydration. Such a state can be fatal in a short amount of time. By selecting one of the three directives on the right, the Nevada Patient’s instructions on receiving fluids artificially can be defined as a refusal or all fluids by I.V., allow a trial period where I.V. fluids are administered with the hope that the Patient can intake his or her fluids again, or to approve of receiving fluids for as long as necessary whenever needed. Additional instructions regarding the Nevada Patient’s instructions on receiving his or her fluids by I.V. can be presented in the space provided.

 

(68) Other Limitations. Denying Specific Procedures And Treatments. A brief list of common procedures has been provided allowing the Nevada Patient to display his or her refusal of intensive care admission, x-rays, I.V., hyperalimentation, lab work, antiarrhythmic drugs, dialysis, and/or electrolyte or acid/base corrective treatments. Space has also been supplied for a report on any other procedures, tests, or treatments the Nevada Patient wants to be withheld.

(69) Full Treatment. If the Nevada Patient wishes to approve and accept all treatment measures to extend life then, Statement 3 should be selected. Additional instructions or limitations can be supplied at will to the space provided in this selection.

Section C Physician Signature

(70) Nevada Physician’s Dated Signature. The Nevada Physician working with the Patient on this document will need to approve its contents as formal medical orders for this Patient’s treatment. To do so, he or she must deliver the current date, sign his or her name, then print his or her name.

(71) Physician Information. In addition to his or her signature, the Nevada Physician must disclose his or her Practice or Office’s address, the phone number required to contact him or her, and the Physician License No. he or she operates under.

Identify Side 2

(72) Nevada Patient Name. Record the full name and date of birth of the Nevada Patient being discussed.

(73) Organ Donation. The Nevada Principal can indicate that he or she wishes to authorize anatomical gifts to be made upon death. This area can be supplied with additional instructions such as to who the anatomical gifts can be made, the approved purpose of the anatomical gifts, or if only some organ, tissue, or body parts are authorized for donation.

Directions For Anatomical Gifts

Section E Advance Directive

(74) Advance Directive Status. It can be crucial to future attending Medical Professionals that any additional documentation regarding the Nevada Patient’s medical preferences be discussed in the MOLST. If the Nevada Patient has not issued an advance directive, then select the “NO” box and continue to the next topic. However, if the Nevada Patient has issued such documentation of his or her medical preferences, then select the “Yes” box.

(75) Unregistered Advance Directive. Indicate if the Nevada Patient has registered his or her advance directive with the Secretary of State with a selection of the appropriate box. If Nevada Patient had not registered his or her advance directive with the Secretary of State then mark the “No” box.

(76) Registered Advance Directive. If the Nevada Principal has registered his or her advance directive then fill in the “Yes” box. You must also record the registration number assigned to the Nevada Patient’s advance directive by the Secretary Of State.

(77) Directive Filing/Storage. If the advance directive has been registered with other entities or stored in other locations, then use the space provided to report on this.

(78) Appointed Agent Information. If the Nevada Patient has appointed one or more Medical Attorneys-in-Fact, then name each one and record each Agent’s telephone number in the spaces provided.

(79) Court Appoint Guardian. Indicate if the Nevada Patient has a Court-Appointed Guardian set in place by selecting the “No” button or the “Yes” button. If “Yes” is selected, then the full name of the Nevada Patient’s Court-Appointed Guardian should be recorded.

Section F Patient/Agent/Parent/Guardian Approval

(80) Consulted Party. The category in which the Entity the Physician has discussed the Patient’s directives with must be solidified. Circle the word “Patient,” “Agent,” “Parent,” or “Guardian” to indicate who the Nevada Physician consulted with to fill out this form.

(81) Nevada Declarant Signature. The Nevada Patient or Proxy must sign his or her name and deliver the calendar date of his or her signature to complete this document’s signature requirement.

(82) Consenting Party. The Party who has granted the Patient’s consent for the content of Sections A and B must be identified. By checking the correct box, it can be indicated if the Consenting Party or Signature Party is the Patient or some other entity. If it is not the Patient then he or she can be defined as the Patient’s Parent (if a minor), the Patient’s Spouse, Adult Child, Court Appointed Guardian, Health Care Agent, or one that you define in the final checkbox choice (“Other”).

(83) MOLST Witness. The Witness who has observed the signature placed above by the Declarant or Consenting Party must sign his or her name. It should be noted that the Witness may not sign this document as a Representative of the Declarant.

(84) Signature Date.

Preparer’s Information

(85) Preparer Name. If the information defining the Patient’s treatment preferences has been provided to this form by someone other than the Nevada Patient or the Signature Physician then, this Preparer should print his or her name.

(86) Preparer Signature Date.

(87) Preparer Signature. This form’s Preparer should sign his or her name.

Section G RegistryEmergency Medical Notice

(88) Living Will Lockbox Confirmation. If the Nevada Physician has informed the Patient behind this POLST, that he or she can submit his or her POLST to the Living Will Lockbox and provided the instructions needed to do so, then the Nevada Physician should confirm this disclosure by initialing the confirmation checkbox provided.

(89) Principal Name. The Nevada Principal has been supplied with a wallet card through this directive package. This item should be filled out and carried on the Nevada Principal’s person at all times since it will inform Nevada First Responders and Physicians that a Durable Power Of Attorney For Health Care has been appointed. Begin with listing the full name of the Nevada Patient or Principal that has completed the Advance Directive above.

(90) Part 1. Primary Agent Name. The full name and contact information for the Primary Nevada Medical Attorney-in-Fact (Health Care Agent) who has been appointed with the power to represent the Principal’s treatment preferences should be documented. This will require a report on the telephone number to reach the Primary Agent at work, home, and/or by cell. If there is another location where the Primary Agent can be reached, then present this to the extra space provided.

 

(91) Part 2. 1st Alternate Agent Name. If the Nevada Medical Attorney-in-Fact cannot be reached or is ineffective (by refusal or revocation) then the 1st Alternate Agent will need to be contacted by First Responders or Physicians using this wallet card. To this end furnish the 1st Alternate Agent’s full name, work phone number, home telephone number, cell phone number, and/or any other phone number where he or she can be reached.

(92) Part 3. 2nd Alternate Agent Name. Just in case the Medical Attorney-in-Fact and 1st Alternate Agent cannot be reached, decline to act, or inform 1st Responders and Physicians that his or her powers have been revoked, report the 2nd Alternate Agent’s full name, and contact telephone numbers.

 

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