A. LIFE-SUSTAINING TREATMENT. If I, Janet Espinoza, am in a terminal condition, or an irreversible coma (or a persistent vegetative state), that my doctors reasonably feel to be irreversible or incurable, I DO NOT want my life to be prolonged and I DO NOT WANT lifesustaining treatment, beyond comfort care, that would serve ONLY to artificially delay the moment of my death. B. NUTRITION AND HYDRATION. If I have a condition stated above, it is my preference TO RECEIVE artificially administered food and fluids. C. PREGNANCY. If I am known to be pregnant, I do not want life-sustaining treatment withheld or withdrawn. However, if at any point it is determined that it is not possible that the embryo/fetus will develop to the point of live birth with continued application of life-sustaining treatment, it is my preference that life-sustaining treatment be withheld or withdrawn. If life-sustaining treatment 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. D. RESUSCITATION. I want cardiopulmonary resuscitation, for example, the use of drugs, electric shock and artificial breathing. E. CARE. Notwithstanding my other directions I do want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is terminal or is irreversible and incurable or I am in a persistent vegetative state. I want my life to be prolonged to the greatest extent possible.

I, Janet Espinoza, of San Rafael, Arizona, as Principal, designate: Agent Name: Address: Phone: Relation, if any: Brian Espinoza 123 Red St Big Bear, AZ 94901 Home: (555)546-3456 Work: (555)415-3456 Husband

© This is a Legal Document ©

as my agent for all matters relating to my health care, including, without limitation, full power to give or refuse consent to all medical, surgical, hospital and related health care, including the provision of life-sustaining treatment and artificially administered food and fluids. This power of attorney is effective on my inability to make or communicate health care decisions. All of my agent's actions under this power during any period when I am unable to make or communicate health care decisions or when there is uncertainty whether I am dead or alive have the same effect on my heirs, devisees and person representatives as if I were alive, competent and acting for myself. If my agent is unwilling or unable to serve or continue to serve, I hereby appoint 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: James Smithe 22 Hayes St Big Bear, AZ 91992 Home: (555)343-1522 Work: (555)554-4523

SECOND ALTERNATE AGENT Agent Name: Address: Phone: Susan Sanchez 99 Apple St San Rafael, AZ 94901 Home: (415)415-4564 Work: (415)415-6663

I have completed and attached a living will for purposes of providing specific direction to my agent in situations that may occur during any period when I am unable to make or communicate health care decisions or after my death. Unless otherwise specified in this document, my agent is directed to implement those choices I have made in the living will. I have completed a prehospital medical directive pursuant to section 36-3251, Arizona Revised Statutes.

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 is a Legal Document ©

(Under Arizona law an autopsy may be required.) If you wish to do so, reflect your desires below: I consent to an autopsy.

(Under Arizona law, you may make a gift of all or part of your body to a bank or storage facility or a hospital, physician or medical or dental school for transplantation, therapy, medical or dental evaluation or research or for the advancement of medical or dental science. You may also authorize your agent to do so or a member of your family may make a gift unless you give them notice that you do not want a gift made. If you do not complete this section, your agent will have the authority to make a gift of part of your body pursuant to law. NOTE: The Donation elections you make in this Health Care Power of Attorney survive your death. If any of the statements below reflects your desire, initial it on the line next to that statement. You do not have to initial any of the statements. If you do not initial any of the statements, your agent and your family will have the authority to make a gift of all or part of your body under Arizona law. _____ I have already signed a written agreement or donor card regarding organ and tissue donation with the following individual or institution: John White.

My agent has authority to carry out all matters relating to my funeral and burial disposition wishes in accordance with this power of attorney, which is effective upon my death. Upon my death, I direct my body to be buried and not cremated.

(Before initialing any choices above you may wish to ask questions of your physician regarding a particular treatment alternative. If you do speak with your doctor it is a good idea to ask your physician to complete this affidavit and keep a copy for his or her file.) I, Dr. Luis Espinoza, have reviewed this guidance document and have discussed with Janet Espinoza any questions regarding the probable medical consequences of the treatment choices provided above. This discussion with Janet Espinoza occurred on the _____ day of ____________________, _____.

© This is a Legal Document ©

I have agreed to comply with the provisions of this directive.

________________________________________ Signature Physician Name: Physician Address: Luis Espinoza 22 13th St San Rafael Pleasent County

This health care directive is made under section 36-3221, Arizona Revised Statutes, and continues in effect for all who may rely on it except those to whom I have given notice of its revocation. (YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY) Signed on _____ day of _______________, _____.

Signature: Name: Address:

________________________________________ Janet Espinoza San Rafael Big Bear County Arizona February 06, 1942 STATEMENT OF WITNESSES

SSN: Birthdate:

I am an adult, and I was present when Janet Espinoza signed (or marked) this Living Will and Health Care Power of Attorney. Janet Espinoza appeared to be of sound mind and free from duress at the time of signing. I am not designated as agent or alternate agent by this document to make medical decisions on Janet Espinoza's behalf, and I am not a person directly involved with the provision of health care to Janet Espinoza at the time this Living Will and Health Care Power of Attorney was signed by Janet Espinoza. I am not related to Janet Espinoza by blood, marriage or adoption and to the best of my knowledge, I am not entitled to any part of Janet Espinoza's estate by will or by operation of law at the time this Living Will and Health Care Power of Attorney was signed by Janet Espinoza.

© This is a Legal Document ©

Witness Signature: Name: Address:

________________________________________ Sara Masonwood 25 H St San Rafael, AZ 94901

Date: _________________________

Witness Signature: Name: Address:

________________________________________ Rose Lynch 25 Wilderness Lan Big Town, AZ 94019

Date: _________________________

© This is a Legal Document ©

Sign up to vote on this title
UsefulNot useful