(1) I, hereby appoint
    as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if 1 become unable to iiiake my own health care dccisio ns.

    (2) Optional: Alternate Agent
    If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I hereby appoint
    as my health care ap=cnt to make any and all health care decisions f’or mc, except to the extent that I state other wise.

    (3) tin less I revoke it or state an expiration date or circumstance5 under which it will expire, this proxy shall remain in effect indefinitely. (Optional: If you want this yr oxy to expire, state the date or coneditions here.) This proxy shall expire (specify date or conditions):

    (4) Optional: I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below. (If you want to. line it your ogent’s authority to ni ake heulth cure clecis ions for you or to give specific instructions, you mcry state your wishes or line itations here.) I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions (attuch additional yoges as nec’essary).’

    In order for your agent to make health care decisions for you about artificial nutrition and hydration (nourish mcut ancl wuter providecl by feecl!* £J tube ancl intraven one liii e) , yo air agent must i easonably know your wishes. You can either tell your ap•ent what your wishes are or include them in this section. See insti uctions for sample language that you could use if you cho ose to include your wishes on this form, including youi wishes abo ut artificial nutrition and hydration.

    (5) Your Identification (please print)
    Your Name
    Your Signature

    Your Address

    (6) Optional: Organ and/or Tissue Donation
    I hereby make an anatomical gift, to be effective upon my death, of:
    (check any that apply)
    O Any needed organs and/or tissues
    The following organs and/or tissues

    D Limitations
    If you do not state youi wislics or insti uctions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.

    Your Signature


    (7) Statement by Witnesses (Witnesses inust be 18 yecirs of uye or olrler ond cannot he the 1 ecilth care agent or altern ate.)
    I declai e that the person who signed this docurrent is personally known to me and appears to be of sound mind and acting of his or her own free wih. He or she signed (or asked another to sign for him or her) this document in my presence.


    Name of Witness 1

    ALtdi ess


    Name of Witness 2
    IP ›’• J