DECLARATION and DURABLE POWER OF ATTORNEY FOR HEALTH CARE I.

DECLARATION
Directive made this ______ day of ____________________, _____. I, Susan Espinoza, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below and do hereby declare: A. LIFE-SUSTAINING PROCEDURES. If at any time I should have an incurable injury, disease, or illness, or be in a continued profound comatose state with no reasonable chance of recovery, certified to be a terminal and irreversible 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 procedures are utilized and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedures deemed necessary to provide me with comfort care. B. NUTRITION AND HYDRATION. If I have a condition stated above, it is my preference TO RECEIVE artificially administered nutrition and hydration (food and fluids). 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. D. AGENT DESIGNATION. If I am unable to make health care decisions for myself, I hereby appoint Billy Espinoza, currently residing at 55 Justice St, San Rafael, LA 94901, as my Agent/Proxy for the purpose of making decisions relating to my health care in my place including decisions to withhold or withdraw life-sustaining procedures consistent with my wishes as stated in this document or otherwise made known. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this Declaration shall be honored by my family and physician(s) as my final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

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II. DURABLE POWER OF ATTORNEY FOR HEALTH CARE

NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO. A. DESIGNATION OF HEALTH CARE AGENT. I, Susan Espinoza, of San Rafael, Louisiana, appoint: Agent Name: Address: Phone: Relation, if any: Billy Espinoza 55 Justice St San Rafael, LA 94901 Home: (415)454-4567 Work: (415)456-3444 Cousin

as my Agent to make health care and personal decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document. NOTICE: Generally you should not appoint any of the following persons as your Agent: (1) your treating physician or health care provider; (2) an employee of your physician or health care provider unless the person is your relative; (3) your residential care provider; or (4) an employee of your residential care provider unless the person is your relative. B. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care. This power of attorney shall take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency. C. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. If my desires regarding a particular health care decision are not known to my Agent, then my Agent shall make the decision for me based upon what my Agent believes to be in my best interests. D. 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:

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FIRST ALTERNATE AGENT Agent Name: Address: Phone: Sarah Adams 315 Gold St San Rafael, LA 94901 Home: (415)345-3456 Work: (415)435-3444

SECOND ALTERNATE AGENT Agent Name: Address: Phone: Alex Cohn 555 Black St San Rafael, LA 94901 Home: (415)333-4444 Work: (415)112-3333

E. 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. I agree that any third party who receives a copy of this document may act under it. Revocation of the Power of Attorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this Power of Attorney. 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. (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.

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Signed on _____ day of ____________________, _____.

Signature: Name: Address:

________________________________________ Susan Espinoza San Rafael _________________ Parish Louisiana February 06, 1942

SSN: Birthdate:

Susan Espinoza has been personally known to me and I believe him or her to be of sound mind. I am not related to Susan Espinoza by blood or marriage and would not be entitled to any portion of Susan Espinoza's estate.

Witness Signature: Name: Address:

________________________________________ Lorena Garcia 80 Sunny St San Rafael, LA 94901

Witness Signature: Name: Address:

________________________________________ Alex Stone 455 Market St San Rafael, LA 94901

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State of Louisiana Parish of _________________________ Be it known on this _____ day of the month of ____________________, _____, before me, the undersigned authority, personally came and appeared Susan Espinoza, to me personally known and known by me to be the person whose genuine signature is affixed to the foregoing document, who signed said document before me and who acknowledged, in my presence, that he/she signed the above and foregoing document as his/her own free act and deed and for the uses and purposes therein set forth and apparent. In witness whereof, the said appearer has signed these presents and I have hereunto affixed my hand and seal on the day and date first above written.

________________________________________ (Signature of Officer) (Seal)

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