DATED: November 30th, 2018

NAME

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POWER OF ATTORNEY FOR PERSONAL CARE

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LAWYER

Barrister and Solicitor

ADDRESS

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 POWER OF ATTORNEY FOR PERSONAL CARE
THIS POWER OF ATTORNEY FOR PERSONAL CARE is given by NAME of the
City of North York, in the Province of Ontario.

1. APPOINTMENT:
I APPOINT my daughters: NAMES(or the survivors thereof)
to act together on the basis of the majority vote to be my
attorney for personal care, pursuant to the Substitute
Decisions Act, and I authorize my attorney to make decisions
concerning my personal care in accordance with the Substitute
Decisions Act and any conditions and restrictions or specific
instructions contained herein. My attorney shall have the
authority to act as my litigation guardian, if one is
required to commence, continue, defend or represent me in
any court proceeding concerning my personal care.

2. CONDITIONS AND RESTRICTIONS:

Without limiting the discretion of my attorneys hereunder,

it is my desire that should I have an incurable injury,
disease or illness regarded as a terminal condition by my
physician and if my physician has determined that the
application of life-sustaining procedure would serve only
artificially to prolong the dying process and that my death
will occur whether or not life-sustaining procedures are
utilized, I direct that such procedures be withheld or
withdrawn and that I be permitted to die with only
administration of medication or the performance of any
medical procedure deemed necessary to provide me with comfort
care or to alleviate pain

3. SPECIFIC INSTRUCTIONS:

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 There are no specific instructions with respect to this
power of attorney for personal care.

4. CONSENT TO TREATMENT:

I authorize my attorney/s, on my behalf, to give or refuse

to consent to treatment to which the Health Care Consent Act,
1996 applies, and in particular I instruct my attorney to
give or refuse consent to the following specified kinds of
treatment under the circumstances detailed below:

Nil

5. ASSESSORS:

If my capacity for personal care is in issue and an

assessment of this capacity is to be performed, I name the
following preferred assessor(s) or class(es) of assessor(s)
to perform such assessment:

Not Applicable.

6. REVOCATION:

Any prior power of attorney for personal care or any prior

power of attorney which affects my personal care previously
given by me is hereby revoked.

7. ALTERNATE:

In the event that my daughters (or the survivors thereof)

is unable to act as my attorney hereunder, then I appoint:

7.1 My grandson, NAME, to be my alternative power of attorneys

for personal care having all authority given to my daughters
NAMES (or the survivors thereof), described herein.

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Executed at the City of Toronto, this 30th day of November, 2018
in the presence of both witnesses, each present at the same
time.

(Each witness shall, if the witness has no reason to believe that

the grantor is incapable of giving a continuing power of attorney,
sign the power of attorney as a witness.)

SIGNED, PUBLISHED AND DECLARED )

byNAMES, as her)
Power of Attorney for Personal Care )
both of us are present at the same time )
And both of us have signed as witnesses at
)________________________________________
his request and with him present, and we ) NAME
have signed with the other witness present. ) (Grantor)

___________________________________ ___________________________________
SIGNATURE - Witness 1 SIGNATURE - Witness 2

Name: ______________________________ Name: ______________________________

Address: Address:

Occupation: __________________________ Occupation: _________________________

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