TERMINAL CARE DOCUMENT

To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to be. To any individual who may become responsible for my health, welfare or affairs. Death is as much a reality as birth, growth, maturity and old age--it is the one certainty of life. If the time comes when I, Dorian Mayhew Rothschild, can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes, while I am still of sound mind. A. EXTRAORDINARY MEASURES. If the situation should arise in which I am in a terminal state or a permanently unconsciousness condition and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I do, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life. I understand that the term "extraordinary measures" means any medical procedure or intervention which utilizes mechanical or other artificial means to sustain, restore, or supplant a vital function which, in the judgment of my attending physician, would serve only to artificially postpone the moment of my death. B. NUTRITION AND HYDRATION. If I have a condition stated above, it is my preference NOT TO RECEIVE artificially administered nutrition and hydration (food and fluids), except as deemed necessary to provide comfort care or to alleviate pain. If any provision in 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. This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that those to whom this will is addressed will regard themselves as morally bound by these provisions.

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Signed this _____ day of _______________, _____.

Signature: Name: Address:

________________________________________ Dorian Mayhew Rothschild San Rafael Willshire County Vermont 123-45-6789 January 12, 1965

SSN: Birthdate:

I am not Dorian Mayhew Rothschild's (i) spouse, (ii) heir, (iii) attending physician or person acting under the direction or control of the attending physician, or (iv) any other person who has at the time of the witnessing of this document any claims against the estate of Dorian Mayhew Rothschild.

Witness Signature: Name: Address:

________________________________________ Ryan J. Jagger 35 Palm Circle Dr. Pillsdale, VT 84855

Witness Signature: Name: Address:

________________________________________ Peter R. Olsen 123 Main St. Pillsdale, VT 85855

Copies of this request have been given to: ________________________________________ ________________________________________ ________________________________________

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