"Durable Power of Attorney for Health Care Decisions
"
"
"To my family, relatives, my friends, my physicians, health care
"providers, community care facilities, and any other person who may
"have an interest or duty:
"
"I, \a, residing in the City/County/Borough/Parish of \b, in the
"State/Commonwealth of \c, being of sound mind, freely, willfully, and
"voluntarily hereby appoint \d, residing in the City/County/Borough/Parish
"of \e, in the State/Commonwealth of \f, as my attorney-in-fact/proxy to
"make health care decisions in my stead and behalf.
"
"In the event that \d is unable or unwilling to serve as my attorney-
"in-fact for the purpose of making health care decisions for me, I
"designate \g, residing in the City/County/Borough/Parish of \h, in the
"State/Commonwealth of \i, to serve as my attorney-in-fact.
"
"At any time that I should for any reason be unable to make such
"decisions for myself, I hereby authorize my attorney-in-fact to make
"any decisions I otherwise could make involving consent, refusal of
"consent, or withdrawal of consent to any care, treatment, service, or
"procedure to maintain, diagnose, or treat me for any physical or
"mental condition whatever.
"
"This appointment shall have no legal force or effect if I revoke it by
"giving notice of such revocation either orally or in writing.
"
"This document revokes any prior Durable Power of Attorney for Health
"Care.
"
"STATEMENT OF DEMANDS
"
"1. If I am in a coma, which my doctors have reasonably concluded is
"irreversible, I demand that life-sustaining or prolonging treatments
"or procedures NOT be used.
"
"2. If I have an incurable or terminal condition or illness and no
"reasonable hope of long term recovery or survival, I demand that life
"sustaining or prolonging treatments NOT be used.
"
"3. If deciding any questions under this document, my attorney-in-fact
"is to consider the relief of suffering and the quality as well the
"possible extension of my life.
"
"Signed on this {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} day of {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}, {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}.
"STATE/COMMONWEALTH OF {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}
"COUNTY/BOROUGH/PARISH OF {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}
"
"BEFORE ME, the undersigned authority, on this day personally appeared
"{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} [name(s)], known to me
"to be the person(s) whose name(s) is(are) subscribed to the foregoing
"instrument, and acknowledged to me that he(she)(they) executed said
"instrument for the purposes and consideration therein expressed.
"
"GIVEN under my hand and seal of office on this {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} day of
