A LIVING WILL A Directive to Withhold or to Provide Treatment and DURABLE POWER OF ATTORNEY FOR HEALTH CARE I.

A LIVING WILL - A DIRECTIVE TO WITHHOLD OR TO PROVIDE TREATMENT

To my family, my relatives, my friends, my physicians, my employers, and all others whom it may concern: Directive made this ______ day of ____________________, _____. I, James Smith, being of sound mind, willfully and voluntarily make known my desire that my life shall not be prolonged artificially under the circumstances set forth below, do hereby declare: A. LIFE-SUSTAINING PROCEDURES. If at any time I should have an incurable injury, disease, illness or condition certified to be terminal by two (2) medical doctors who have examined me, and the application of life-sustaining procedures of any kind would serve only to prolong artificially my life, and where a medical doctor determines that my death is imminent, whether or not life-sustaining procedures are utilized, or I have been diagnosed as being in a persistent vegetative state, I direct that the following expression of my intent be followed and that I be permitted to die naturally, and that I receive any medical treatment or care that may be required to keep me free of pain or distress. If at any time I should become unable to communicate my instructions, then I direct that all medical treatment, care, and nutrition and hydration necessary to restore my health, sustain my life, and to abolish or alleviate pain or distress be provided to me. Nutrition and hydration shall not be withheld or withdrawn from me if I would die from malnutrition or dehydration rather than from my injury, disease, illness or condition. B. PREGNANCY. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy. However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point. If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant. C. PROXY. In the absence of my ability to give directions regarding the use of life-sustaining procedures, I hereby appoint Adrian Smith, currently residing at 50 Happy Lane, Big City, ID 94901, as my Attorney-in-fact/Proxy for the making of decisions relating to my health care in my place. It is my intention that this appointment shall be honored by my Attorney-in-fact/Proxy, and by my family, relatives, friends, physicians and lawyer as the final expression of my legal right to
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refuse medical or surgical treatment, and I accept the consequences of such a decision. I HAVE DULY EXECUTED A DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS ON THIS DATE.

II. DURABLE POWER OF ATTORNEY FOR HEALTH CARE

A. DESIGNATION OF HEALTH CARE AGENT. I, James Smith, of San Rafael, Idaho, do hereby designate and appoint: Agent Name: Address: Phone: Relation, if any: Adrian Smith 50 Happy Lane Big City, ID 94901 Home: (415)453-3334 Work: (415)456-5554 Cousin

(None of the following may be designated as your Agent: (1) your treating health care provider, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility, or (4) a nonrelative employee of an operator of a community care facility.) as my Attorney-in-Fact (Agent) to make health care decisions for me as authorized in this document. For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical condition, including the provision of artificially provided nutrition and hydration. B. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care. This power of attorney shall not be affected by my subsequent incapacity. C. AUTHORITY OF AGENT. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In exercising the authority under this Durable Power of Attorney for Health Care, my Agent shall act consistently with my desires as stated in this document or otherwise made known to my Agent including, but not limited to, my desires concerning obtaining or refusing or withdrawing lifeprolonging care, treatment, services, and procedures. My Agent's authority is subject to the special provisions and limitations stated in my living will. If my desires regarding a particular health care decision are not known to my Agent, then my Agent shall make the decision for me based upon what my Agent believes to be in my best interests. D. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my Agent has the power and authority to:
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a. Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records; b. Consent to the disclosure of this information to others. E. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to implement the heath care decisions that my Agent is authorized by this document to make, my Health Care Agent has the power and authority to execute on my behalf any of the following: a. Documents to authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care or assisted living or similar facility or service; b. Documents titled or purporting to be "Consent to Permit Treatment" or "Refusal to Permit Treatment"; or c. Any necessary waiver or release from liability required by a hospital or physician. F. ANATOMICAL GIFTS. I authorize my Agent, to the extent permitted by law, to make anatomical gifts of part or all of my body for medical purposes, to the extent permitted by law. G. DESIGNATION OF ALTERNATE AGENT. If the person designated as my Agent is not available or unable to act, I designate the following persons to serve as my Agent to make health care decisions for me as authorized by this document, who serve in the following order: FIRST ALTERNATE AGENT Agent Name: Address: Phone: Brian Hernandez 50 Lucas Valley Road Big City, ID 94901 Home: (415)456-4455 Work: (415)545-4345

SECOND ALTERNATE AGENT Agent Name: Address: Phone: Alex Green 83 Bright Ave Big City, ID 94901 Home: (415)445-45555 Work: (415)455-55444

H. PRIOR DESIGNATIONS REVOKED. I revoke any prior Durable Power of Attorney for Health Care.

III. GENERAL PROVISIONS

A. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for
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any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them. B. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable. C. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions. DATE AND SIGNATURE OF PRINCIPAL (You Must Date and Sign This Document) I understand the full importance of this directive and am emotionally and mentally competent to make this directive. No participant in the making of this directive or in its being carried into effect, whether it be a medical doctor, my spouse, a relative, friend or any other person, shall be held responsible in any way, legally, professionally or socially, for complying with my directions. I sign my name to this document on the _____ day of ____________________, _____, at _________________________, Idaho.

Signature: Name: Address:

________________________________________ James Smith San Rafael Marin County Idaho February 06, 1942 STATEMENT OF WITNESSES

SSN: Birthdate:

(This document will not be valid unless it is signed by two qualified witnesses who are present when you sign or acknowledge your signature. If you have attached any additional pages to this form, you must date and sign each of the additional pages at the same time you date and sign this document.) (This document must be witnessed by two qualified adult witnesses. None of the following may be used as a witness: (1) a person you designate as your Agent or Alternate Agent, (2) a health care provider, (3) an employee of a health care provider, (4) the operator of a community care facility,
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(5) an employee of an operator of a community care facility. At least one of the witnesses must make the additional declaration set out following the place where the witnesses sign.) I declare under penalty of perjury under the laws of Idaho that the person who signed or acknowledged this document is personally known to me (or proved to me on the basis of convincing evidence) to be James Smith, that James Smith signed or acknowledged this document in my presence, that James Smith appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as Attorney-in-Fact by this document, and that I am not a health care provider, an employee of a health care provider, the operator of a community care facility, nor an employee of an operator of a community care facility.

Witness Signature: Name: Address:

________________________________________ Susan Rose 500 D St Big City, ID 94901

Date: _________________________

Witness Signature: Name: Address:

________________________________________ Sara Garcia 80 H St Big City, ID 94901

Date: _________________________ (At least one of the above witnesses must also sign.) I further declare under penalty of perjury under the laws of Idaho that I am not related to James Smith by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of James Smith upon the death of James Smith under a will now existing or by operation of law.

Signature: ________________________________________

Signature: ________________________________________

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