This government document is issued by Department of Aging for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:p5rt2izphxk&q=https://www.aging.pa.gov/publications/policy-procedure-manual/Documents/Chapter%2520V_Care%2520Management/Appx%2520C.1%2520Voter%2520Preference%2520Form%2520-%2520English.pdf&sa=U&ved=2ahUKEwio-ais5q_8AhW_UKQEHZpLAh84ChAWegQIBxAB&usg=AOvVaw0x2JFtUMgDNDXQfd3QfFfk