DECLARATION

Declaration made this ______ day of ____________________, _____. I, Dorian Mayhew Rothschild, 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 PROCEDURES. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition or a permanently unconscious 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 within a relatively short time, or that I will remain in a permanently unconscious condition, and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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. 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 me with comfort care. 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. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this Declaration shall be honored by my family physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

I fully understand that action taken in accordance with this declaration might result in my death, and I am emotionally and mentally competent to make this declaration.

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Date Signed: ____________________ ______, _____.

Signature: Name: Address:

________________________________________ Dorian Mayhew Rothschild 60 Arthur St. San Rafael Darton County Michigan 123-45-6789 February 23, 1965

SSN: Birthdate:

Dorian Mayhew Rothschild, the Declarant, has been personally known to me and appears to be of sound mind and under no duress, fraud, or undue influence. I am not (i) Dorian Mayhew Rothschild's spouse, parent, child, grandchild, sibling, (ii) entitled to any portion of the estate of Dorian Mayhew Rothschild according to the laws of Intestate Succession or under any will or codicil of Dorian Mayhew Rothschild, (iii) Dorian Mayhew Rothschild's physician or patient advocate, (iv) an employee of a home for the aged where Dorian Mayhew Rothschild resides, (v) an employee of a health facility that is treating Dorian Mayhew Rothschild, or (vi) an employee of a life or health insurance provider for the patient. I am at least 18 years of age.

Witness Signature: Name: Address:

________________________________________ Marian G. Davis 35 Palm Circle Dr. Fellings, MI 85350

Witness Signature: Name: Address:

_________________________________________ Rob Mackabee 123 Main St. Sharpsville, MI 85350

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