LIVING WILL and DESIGNATION OF HEALTH CARE SURROGATE I.

LIVING WILL
Declaration made this ______ day of ____________________, _____. I, Susan Smith, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare: A. LIFE-PROLONGING PROCEDURES. If at any time I am BOTH mentally and physically incapacitated AND __________ (initial) I have a terminal condition __________ (initial) or I have an end-state condition __________ (initial) or I am in a persistent vegetative state AND if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that lifeprolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the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 or to alleviate pain. B. NUTRITION AND HYDRATION. If I have a condition stated above, it is my preference TO RECEIVE artificially administered nutrition and hydration (food and fluids). C. 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-prolonging procedures, it is my preference that this document be given effect at that point. If life-prolonging 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.

II. DESIGNATION OF HEALTH CARE SURROGATE

A. DESIGNATION OF HEALTH CARE SURROGATE. In the event that I have been determined to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my Surrogate for health care decisions:

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Surrogate Name: Address: Phone: Relation, if any:

Brian James 123 Gold Ave San Rafael, FL 94901 Home: (415)435-3434 Work: (415)455-3344 Nephew

B. AUTHORITY OF SURROGATE. I fully understand that this designation will permit my designee to make health care decisions and to provide, withhold, or withdraw consent on my behalf; to apply for public benefits to defray the cost of health care; to have access to my records necessary to make decisions or apply for benefits; and to authorize my admission to or transfer from a health care facility. I specifically give my Surrogate the authority to provide, withhold or withdraw consent to the provision of life-prolonging procedures on my behalf including the provision of artificially provided nutrition and hydration. My Surrogate must act consistently with my desires as stated in this document or otherwise made known. C. DESIGNATION OF ALTERNATE SURROGATE. If my Surrogate is unwilling or unable to perform his/her duties, I wish to designate as my Alternate Surrogate: FIRST ALTERNATE SURROGATE Surrogate Name: Address: Phone: Jake Smiley 34 Golden Rule Ave Marin, FL 94901 Home: (415)434-3435 Work: (415)342-4532

SECOND ALTERNATE SURROGATE Surrogate Name: Address: Phone: Mikey Lin 100 Earth St San Rafael, FL 94901 Home: (415)415-3333 Work: (415)345-5553

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 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.

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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 LIVING WILL AND DESIGNATION IN THE PRESENCE OF TWO WITNESSES) I affirm that this Living Will and Designation is not being made as a condition of treatment or admission to a health care facility. I have read and understand the contents of this document and the effect of this grant of powers to my Surrogate. I am emotionally and mentally competent to make this declaration. Signed on _____ day of _______________, _____.

Signature: Name: Address:

________________________________________ Susan Smith San Rafael Marin County Florida February 06, 1942

SSN: Birthdate:

We, the undersigned witnesses, state that in the presence of each other and Susan Smith we have witnessed the signing of this Living Will and Designation by Susan Smith. I have not been appointed as Susan Smith's Surrogate or Alternate Surrogate. At least one witness is not Susan Smith's spouse nor blood relative.

Witness Signature: Name: Address:

________________________________________ Alex Green 345 Factory St San Rafael, FL 94901

Date: ______________________________

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Witness Signature: Name: Address:

_________________________________________ Doug Johnson 888 12th Street San Rafael, FL 94901

Date: ______________________________

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