DECLARATION and DURABLE POWER OF ATTORNEY FOR HEALTH CARE I.

DECLARATION
NOTICE: This document has significant medical, legal and possible ethical implications and effects. Before you sign this document, you should become completely familiar with these implications and effects. The operation, effects, and implications of this document may be discussed with a physician, a lawyer and a clergyman of your choice. Declaration made this _____ day of ____________________, _____. I, Sammy 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, do hereby declare: A. LIFE-SUSTAINING PROCEDURES. If at any time I should have an incurable injury, disease or other illness certified to be a terminal condition or a permanently unconscious condition (irreversible coma) by two (2) physicians who have personally examined me, one (1) 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, or that I will remain in a permanently unconscious condition (irreversible coma) and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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 treatment, it is my preference that this document be given effect at that point. 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. PROXY. If, in spite of this declaration, I am comatose or otherwise unable to make treatment decisions for myself, I hereby designate Adriana Espinoza, currently residing at 50 Justice St., San Rafael, WY 94901, to make treatment decisions for me.

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In the absence of my ability to give directions regarding the use of life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) and agent as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from this refusal. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

II. DURABLE POWER OF ATTORNEY FOR HEALTH CARE

A. DESIGNATION OF HEALTH CARE AGENT. I Sammy Espinoza, of San Rafael, Wyoming, appoint: Agent Name: Address: Phone: Relation, if any: Adriana Espinoza 50 Justice St. San Rafael, WY 94901 Home: (415)435-34345 Work: (415)455-3344 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: None of the following individuals may be appointed or act as your Health Care Agent: (1) your treating health care provider, (2) an employee of your treating health care provider, (3) an operator of a community care facility or residential care facility, (4) an employee of an operator of a community care facility or residential care facility. EXCEPT any employee of the above institutions may be designated as the Attorney-in-Fact if the employee so designated is related to you by blood, marriage or adoption. 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, including the authority to direct the withholding and withdrawal of artificially provided food and fluids. 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.
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D. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS. I authorize my Agent, to the extent permitted by law, to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains. E. 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: Mike Smith 400 Orange St San Rafael, WY 94901 Home: (415)345-2345 Work: (415)456-3456

SECOND ALTERNATE AGENT Agent Name: Address: Phone: Sarah Rose 555 Black St San Rafael, WY 94901 Home: (415)999-8989 Work: (415)999-8880

F. 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:

________________________________________ Sammy Espinoza San Rafael Marin County Wyoming February 06, 1942

SSN: Birthdate:

Sammy Espinoza has been personally known to me and I believe Sammy Espinoza to be of sound mind. I did not sign Sammy Espinoza's signature above or at the direction of Sammy Espinoza. I am not related to Sammy Espinoza by blood or marriage, entitled to any portion of the estate of Sammy Espinoza according to the laws of Intestate Succession or under any Will or Codicil of Sammy Espinoza, or directly financially responsible for Sammy Espinoza's medical care.

Witness Signature: Name: Address:

________________________________________ James Peter 530 9th St San Rafael, WY 94901

Date: _________________________

Witness Signature: Name: Address:

________________________________________ Ben Green 8080 Flip St San Rafael, WY 94901

Date: _________________________

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