I, Dorian Mayhew Rothschild, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below. A. LIFE-SUSTAINING TREATMENT. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition. I also direct my attending physician to withhold or withdraw lifesustaining treatment that serves only to prolong the process of my dying, if I should be in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing lifesustaining treatment. B. NUTRITION AND HYDRATION. If I have a condition stated above, it is my preference NOT TO RECEIVE tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water). C. OTHER REQUESTS. In addition, if I am in a condition or state described above, I feel especially strong about the following forms of treatment: I do want cardiac resuscitation. I do not want mechanical respiration. I do not want blood or blood products. I do want any form of surgery or invasive procedures. I do not want kidney dialysis. I do want antibiotics. D. SURROGATE DESIGNATION. I do want to designate another person as my Surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or state of permanent unconsciousness. I hereby designate Mary Rothschild currently residing at 60 Arthur St., Lexington, PA 74733, as my Surrogate. If the person designated as my Surrogate is not able to act, I designate Ryan B. Jagger currently residing at 35 Palm Circle Dr., Rockerdale, PA 74733, as my Alternate Surrogate. 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 ©

I made this declaration on the _____ day of _______________, _____.

Signature: Name: Address:

________________________________________ Dorian Mayhew Rothschild Rockerdale Lexington County Pennsylvania 123-45-6789 May 22, 1970

SSN: Birthdate:

STATEMENT OF WITNESSES Dorian Mayhew Rothschild or the person on behalf of and at the direction of Dorian Mayhew Rothschild knowingly and voluntarily signed this writing by signature or mark in my presence. Each of us is at least 18 years of age.

Witness Signature: Name: Address:

________________________________________ Peter R. Olsen 440 Montgomery St. Billington, PA 94103

Witness Signature: Name: Address:

_________________________________________ Gina Terza 123 Main St. Adamtown, PA 74354

© This is a Legal Document ©

Sign up to vote on this title
UsefulNot useful