DECLARATION and HEALTH CARE PROXY I.

DECLARATION
A. LIFE-SUSTAINING TREATMENT. If I should have an incurable or irreversible condition that will cause my death within a relatively short time, and I am no longer to make decisions regarding my medical treatment, or if I should become permanently unconscious, I direct my attending physician, pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to withhold or withdraw life-sustaining treatment that only prolongs the process of dying and is not necessary to my comfort or to alleviate pain. B. NUTRITION AND HYDRATION. If I have a condition stated above, it is my specific directive that nutrition and hydration may not be withheld. C. PREGNANCY. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy. However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point. If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.

II. HEALTH CARE PROXY
A. DESIGNATION OF HEALTH CARE PROXY. If I should become permanently unconscious, incompetent, or otherwise mentally or physically incapable of communication, I direct my attending physician, pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to follow the instructions of my Agent whom I appoint as my Health Care Proxy ("Agent") to decide whether life-sustaining treatment (including the withdrawal and withholding of artificially supplied nutrition and fluids) should be withheld or withdrawn: Agent Name: Address: Phone: Relation, if any: Mike Smith 8 Hayes St Big City, AK 94902 Home: (535)331-4564 Work: (414)425-3433 Cousin

In exercising this authority, my Agent shall make health care decisions that are consistent with my

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desires as stated in this document or otherwise made known to my Agent. B. DESIGNATION OF ALTERNATE AGENT. If the person designated as my Agent is not available or unable to act, I designate the following persons to serve as my Agent to make health care decisions for me as authorized by this document, who serve in the following order: FIRST ALTERNATE AGENT Agent Name: Address: Phone: Eddy Sanchez 12 Market St Big City, AK 94902 Home: (315)323-3434 Work: (315)234-1234

SECOND ALTERNATE AGENT Agent Name: Address: Phone: Sara Rose 55 13th St Big City, AK 94902 Home: (342)232-1245 Work: (416)234-3456

C. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian.

III. GENERAL PROVISIONS
A. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them. B. SEVERABILITY. If any provision of 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. C. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.

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(YOU MUST DATE AND SIGN THIS DOCUMENT) I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration. Signed on ______ day of ____________________, _____.

Signature: Name: Address:

________________________________________ Janet Espinoza San Rafael Big Bear County Arkansas February 06, 1942

SSN: Birthdate:

Janet Espinoza voluntarily signed this writing in my presence. We, the undersigned, state that we are both at least 18 years of age.

Witness Signature: Name: Address:

________________________________________ Suzie Waters 88 B St Big City, AK 94902

Date: _________________________

Witness Signature: Name: Address:

________________________________________ Alex Stone 33 H St Big City, AK 94902

Date: _________________________

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