ADVANCE DIRECTIVE FOR HEALTH CARE I.

ADVANCE DIRECTIVE FOR HEALTH CARE - LIVING WILL

Declaration made this _____ day of ____________________, _____. I, Maren J. Olsen, being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, hereby declare: A. LIFE-SUSTAINING TREATMENT. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining treatment is provided, and where the application of life-sustaining treatment would serve only to artificially prolong the dying process, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care. 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. If lifesustaining treatment 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.

II. ADVANCE DIRECTIVE FOR HEALTH CARE DURABLE POWER OF ATTORNEY FOR HEALTH CARE
A. DESIGNATION OF HEALTH CARE AGENT. I, Maren J. Olsen, of Blueville, New Jersey, appoint Agent Name: Address: Phone: Relation, if any: John W. Olsen 35 Palm Circle Dr. Corte Madera, NJ 75665 Home: (845) 845-1234 Work: (845) 607-1943 Husband

as my Agent to make health care and personal decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document. NOTICE: An operator, administrator or employee of a health care institution in which you are a patient or resident shall NOT serve as your Health Care Agent unless the operator, administrator or employee is related to you by blood, marriage or adoption. This restriction does not apply to a physician, if the physician does not serve as your attending physician and your Health Care Agent
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at the same time. 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 take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency. C. GENERAL STATEMENT OF AUTHORITY GRANTED. 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. "Health Care Decision" means a decision to accept or to refuse any treatment, service or procedure used to diagnose, treat or care for my physical or mental condition, including lifesustaining treatment. My Agent has the authority to direct the withdrawal and withholding of artificially provided food and fluids. My Agent may also accept or refuse the services of a particular physician, nurse, other health care professional or health care institution, including a decision to accept or to refuse a transfer of care. In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. In making any decision, my Agent shall attempt to discuss the proposed decision with me to determine my desires if I am able to communicate in any way. 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. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS. I authorize my Agent, to the extent permitted by law, to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains. E. DURATION. I understand that this power of attorney becomes operative when (1) it is transmitted to my attending physician or to the health care institution responsible for my health care, and (2) my attending physician determines in writing that I lack the capacity to make a particular health care decision. My attending physician's determination of a lack of decision-making capacity shall be confirmed in writing by one or more physicians.

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 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
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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. (YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY) I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration. Signed on _____ day of _______________, _____.

Signature: Name: Address:

________________________________________ Maren J. Olsen Blueville Fork County New Jersey 123-45-6789 May 04, 1968

SSN: Birthdate:

READ AND CAREFULLY FOLLOW THE WITNESSING PROCEDURE. IT REQUIRES TWO WITNESSES, A NOTARY, OR A LAWYER TO ENSURE THAT THIS DOCUMENT WILL BE RECOGNIZED AS LEGALLY BINDING.

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STATE OF ___________________________ COUNTY OF _________________________ I CERTIFY that on the _____ day of _______________, _____, Maren J. Olsen personally came before me and this person acknowledged under oath, to my satisfaction, that this person: (a) is named in and personally signed the foregoing instrument, (b) is of sound mind and free of duress or undue influence, and (c) signed the same as his or her voluntary act and deed for the uses and purposes therein expressed. My Commission Expires (if applicable): _________________________

___________________________________ NOTARY PUBLIC OR OTHER OFFICIAL

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