Wt your mame and thonane, heme aroes and elophorenumar ofthe pecson you are selecting a8 your agin. 2.Nyoubave spect structions fr our age yeushouldeterhom ne Ao. fou ish Fen your agents author Iman ny. jou sould say scare. youdonat ste ny ists, yor agent vale afowes ona Balhae dolsons ‘thar you could ved, inciting the dsonte consent Tortus sustaining eat. 3.Youray nts the rane, home aess and ‘elephone umber ofan sitemate agent Tis form lransin a ini ios, ynusetaneoiaton ‘atcereanaton tere sepeaton. Tes pcton |soptonaland souk be ‘edn onl yar tho nh eae paxy ep, 5 Youmust dat and sin ‘he prog.sfyouare unable fosgnyousl,yousey Cec cononne ata ln Inyeurpessnea Beso ‘einlae yur sees BTW witnesses atlnast years of age mast sig your proxy The porson ‘whois spond agent ‘or ahomste agent cannot slanasa enacs Health Care Proxy Form |. Proxy designation L Army Lindenbaum Beshparpulae Atbred Yorger Wl 3204 East 1O™ Se Apt G4 Boom inngten ZN (4126 ~ 0706 as my health care agent to make any and all heath care decisions for me, except to che extent that I seate other- ‘wise, This proxy shall cake effect when and if become unable to make my own health care decisions. 2. Optional instructions I direct my agenc to make health care decisions in accord with my wishes and limitations as stated below, or ashe cor she otherwise knows (Attach additional pages if necessary) ZT ual wot be an aejan donor, (ns. an gon or agent nl rite structions nt arial ron nd by ean (engin), or gentile econ abou oii marion hydration Sc stacion fr alae ange ysl na a oe wis arabe Os ents) 3. Optional: Organ and/or Tissue Donation Thereby make an anatomical gift ro be effective upon my death of: savy NEEDED issues on oneans 4, Alternate proxy designation ‘Name and contact information of substitute ot fillin proxy ifthe person T appoint above is unable, unwilling or ‘unavailable ro act as my health cate agent. 5. Conditions ‘Unless | revoke it, this proxy shall remain in effect indefinitelv: or until the date or conditions stated below. ‘This. proxy shall expire (specific date or conditions, if desired): Unt] we gre po longer a Couple or on Aum Catore. teems 6. Signature Arta4 Web Dee /2, 2021 1724 Purpose Dove vieghaia, Becetn va Statement by Witnesses (must be [8 or older) {declare that che person who signed this docamentis personally known to me and appeus to be of sound mind and act- ingofhisor heron fre yi He o ys asked another co sign for him or her) this document in wrTness 2 Y fpr Ve th. al f f wypoe- Dye“This ning ls egal secure seting forth ‘your scion ogang medical reatmet You have ig reuse ‘ry ireatmontyeudo nat wat, nd you may request the care you vat. Yournay make changes Inanyo hse dse- sions. or adi changes fo centr than fo Your personal wishes Signand date herein the presence of tn adult neste, wo should alsa sign. Kogp the siged ornat vite your personal paper at hone. Gio tapies ofthe signa signal your dct fay lawyer and others who might be invabed in youreare, New York Living Will ‘This Living Will hasbeen prepared to canformto the late inthe State of Newe York, asset forth in the case of re Weste chester County Medical Center, 72 Nx.2d 517 (xg88)_ ln that case the Court approved of the we of a Living Wil, stating ‘that the “idea situation is one in wich the patient's wishes were expresed in some form of writing, perhaps a Tring will” L Amy Lind@no aun __ -beingofsound mind-make this satement asa directive to be followed if become permanently unable to participate in decisions regarding my medical care. These instructions reflect my firm and settled commitment to decline medical treatment under the circumstances indicated below: 1 direct my attending physician to withhold or withdraw teatment thar merely prolongs my dying. if [should be ‘in an incurable or irreversible mental or physical condition with no reasonable expectation of recovery. “These inseructions apply if | am a) in a terminal condition; b) permanently unconscious; orc) minimally conscious bur have irreversible brain damage and will never regain the ability co make decisions and express mywishes. | direct thar treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that sight ocene by withholding or withdrawing ereatment. ‘While [understand chat Lam not egaly required to be specific about future treatments, if Tam in the condition(s) described above I feel especially strongly about the following forms of treatment: > Ido not want cardiac resuscitation. > donot want mechanical respiration, > Idonot wane tube feeding. > Tdo not wane antibiotics. > Tdo wane maximum pain relief Other directions (insere personal insruetions): These directions express my legal right ro refuse treatment; under the law of New York. Tintend my instructions to be caried out, unless I have rescinded them in writing or by clearly indicating that T have changed may mind. Ay dine Pee (2, 2621 } eT oe, ec es Efe, ZO, VpOse, yi re enact Wy tif LZ {Van ‘ 7 Betty HA] “oh lOve Vergara Gch \