I, Dorian Mayhew Rothschild, understand this document allows me to do ONE OR BOTH of the following: Name another person (called the health care agent) to make health care decisions for me. My health care agent must make health care decisions for me based on the instructions I provide in this document, if any, the wishes I have made known to him or her, or must act in my best interest if I have not made my health care wishes known. AND/OR Give health care instructions to guide others making health care decisions for me. If I have named a health care agent, these instructions are to be used by the agent. These instructions may also be used by my health care providers, others assisting with my health care and my family, in the event I cannot make decisions for myself.

A. APPOINTMENT OF HEALTH CARE AGENT. I, Dorian Mayhew Rothschild, of Staples, Minnesota, trust and appoint: Agent Name: Address: Phone: Relation, if any: Peter R. Olsen 123 Main St. Mill Valley, MN 37343 Home: (405) 456-1543 Work: (034) 394-1244 Friend

as my health care agent to make any health care decisions for me when, in the judgment of my attending physician, I lack decision-making capacity to make or communicate the decision on my behalf. NOTICE: You should not appoint any of the following persons as your agent unless the individual appointed is related to you by blood, marriage, registered domestic partnership, or adoption: (1) your health care provider or (2) an employee of your health care provider. B. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, my health care agent is automatically given the powers listed below in (A) through (D). My health care agent must follow my health care instructions in this document or any other instructions I have given to my agent. If I have not given health care instructions, then my agent must act in my best interest.

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My health care agent has the power to: (A) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care, treatment, service, or procedures. This includes deciding whether to stop or not start health care (including artificially administered nutrition or hydration) that is keeping me or might keep me alive, and deciding about intrusive mental health treatment. (B) Choose my health care providers. (C) Choose where I live and receive care and support when those choices relate to my health care needs. (D) Review my medical records and have the same rights that I would have to give my medical records to other people. C. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS. I do not authorize my Agent to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains. D. NOMINATION OF GUARDIAN. I understand that under Minnesota law, the appointment of the health care agent in a health care directive is considered a nomination of that person to act as guardian or conservator if one needs to be appointed. However, if a guardian or conservator of my person is to be appointed for me, I nominate Name: Address: Mary Rothschild 60 Arthur St. Muron, Minnesota 37354

to serve as my guardian or conservator.

I, Dorian Mayhew Rothschild, being an adult of sound mind, willfully and voluntarily give these instructions. These are instructions for my health care when I am unable to decide or speak for myself. These instructions must be followed (so long as they address my needs). A. Life-sustaining Treatment. If at any time I should have an incurable injury, disease, illness, or condition certified to be a terminal 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 whether or not life-sustaining treatment is used, and where the application of lifesustaining treatment would serve only to artificially prolong the dying process, I direct that such treatment 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
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provide me with comfort care. It is my intent that the term "terminal condition" does not include a permanently unconscious condition or coma. B. Artificial Nutrition or Hydration. I recognize that if I reject artificially administered sustenance, then I may die of dehydration or malnutrition rather than from my illness or injury. The following are my feelings and wishes regarding artificially administered sustenance should I have a terminal condition: 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. C. These are my beliefs and values about my health care: (You may, but need not, give your religious or spiritual beliefs, goals for health care, fears about health care, philosophy, or other personal values that you feel are important. You may also state preferences concerning the location of your care): _________________ D. Other Specific Requests. (You may state your preferences for your physician, where you would like to receive health care, where you would like to die, or what happens to your body after death.): _________________ E. Organ Donation. I do not wish to donate my organs or tissues upon my death.

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. (YOU MUST DATE AND SIGN THIS DOCUMENT) I am thinking clearly, I agree with everything that is written in this document, and I have made this document willingly.

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Signed on _____ day of ____________________, _____.

Signature: Address:

SSN: Birthdate:

________________________________________ Dorian Mayhew Rothschild Staples Parish County Minnesota 123-45-6789 July 15, 1971

If I cannot sign my name, I can ask someone to sign this document for me.

____________________________________ Signature of the person who I asked to sign this document for me. ____________________________________ Printed name of the person who I asked to sign this document for me. STATE OF MINNESOTA, COUNTY OF _________________________ In my presence on ______________ (date), Dorian Mayhew Rothschild acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. I am not a health care agent or alternative health care agent appointed in the foregoing instrument.

________________________________________ Notary Public

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