REVOCATION OF PETER F.

OLSEN
I, Dorian Mayhew Rothschild of 60 Arthur St., San Rafael, California 94901, SSN: , hereby revoke my Peter F. Olsen dated April 30, 2012. The power and authority granted under the Peter F. Olsen for making health care decisions on my behalf is revoked and withdrawn and this document provides notice of such revocation. Dated this _____ day of _______________, _____, at San Rafael, California.

____________________________________________________ Dorian Mayhew Rothschild WITNESS SIGNATURE

Witness Signature: Witness Name: Witness Address:

__________________________________________ Ryan H. Jagger 35 Palm Circle Dr. Corte Madera, CA 95422 __________________

Date:

Witness Signature: Witness Name: Witness Address:

__________________________________________ Mary Rothschild 440 Montgomery St. San Francisco, CA 94103 __________________

Date:

Names of institutions/individuals who have been provided a copy of this revocation: - Dr. Maria Q. Pedula