INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE THIS IS AN IMPORTANT LEGAL DOCUMENT.

BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS: Except if you say otherwise in the directive, this directive gives the person you name as your health care agent the power to make any and all health care decisions for you when you lack the capacity to make health care decisions for yourself (in other words, you no longer have the ability to understand and appreciate generally the nature and consequences of a health care decision, including the significant benefits and harms of and reasonable alternatives to any proposed health care). Health care means any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition. Your health care agent, therefore, will have the power to make a wide range of health care decisions for you. Your health care agent may consent (in other words, give permission), refuse to consent, or withdraw consent to medical treatment, and may make decisions about withdrawing or withholding life-sustaining treatment. Your health care agent cannot consent to or direct any of the following: commitment to a state institution, sterilization, or termination of treatment if you are pregnant and if the withdrawal of that treatment is deemed likely to terminate the pregnancy, unless the treatment will be physically harmful to you or prolong severe pain which cannot be alleviated by medication. You may state in this directive any treatment you do not want, or any treatment you want to be sure you receive. Your health care agents power will begin when your doctor certifies that you lack the capacity to make health care decisions (in other words, that you are not able to make health care decisions). If for moral or religious reasons you do not want to be treated by a doctor or to be examined by a doctor to certify that you lack capacity, you must say so in the directive and you must name someone who can certify your lack of capacity. That person cannot be your health care agent or alternate health care agent or any person who is not eligible to be your health care agent. You may attach additional pages to the document if you need more space to complete your statement. If you want to give your health care agent power to withhold or withdraw medically administered nutrition and hydration, you must say so in your directive. Otherwise, your health care agent will not be able to direct that. Under no conditions will your health care agent be able to direct the withholding of food and drink that you are able to eat and drink normally. Your agent shall be directed by your written instructions in this document when making decisions on your behalf, and as further guided by your medical condition or prognosis. Unless you state otherwise in the directive, your agent will have the same power to make decisions about your health care as you would have made, if those decisions by your health care agent are made consistent with state law. It is important that you discuss this directive with your doctor or other health care providers before you sign it, to make sure that you understand the nature and range of decisions which could be

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made for you by your health care agent. If you do not have a health care provider, you should talk with someone else who is knowledgeable about these issues and can answer your questions. Check with your community hospital or hospice for trained staff. You do not need a lawyers assistance to complete this directive, but if there is anything in this directive that you do not understand, you should ask a lawyer to explain it to you. The person you choose as your health care agent should be someone you know and trust, and he or she must be at least 18 years old. If you choose your health or residential care provider (such as your doctor, advanced practice registered nurse, or an employee of a hospital, nursing home, home health agency, or residential care home, other than a relative), that person will have to choose between acting as your health care agent or as your health or residential care provider, because the law does not allow a person to do both at the same time. You should consider choosing an alternate health care agent, in case your health care agent is unwilling, unable, unavailable or not eligible to act as your health care agent. Any alternate health care agent you choose will then have the same authority to make health care decisions for you. You should tell the person you choose that you want him or her to be your health care agent. You should talk about this directive with your health care agent and your doctor or advanced practice registered nurse and give each one a signed copy. You should write on the directive itself the people and institutions who will have signed copies. Your health care agent will not be liable for health care decisions made in good faith on your behalf. EVEN AFTER YOU HAVE SIGNED THIS DIRECTIVE, YOU HAVE THE RIGHT TO MAKE HEALTH CARE DECISIONS FOR YOURSELF AS LONG AS YOU ARE ABLE TO DO SO, AND TREATMENT CANNOT BE GIVEN TO YOU OR STOPPED OVER YOUR CLEAR OBJECTION. You have the right to revoke the power given to your health care agent by telling him or her, or by telling your health care provider, orally or in writing, that you no longer want that person to be your health care agent. YOU HAVE THE RIGHT TO EXCLUDE OR STRIKE REFERENCES TO APRNS IN YOUR ADVANCE DIRECTIVE AND IF YOU DO SO, YOUR ADVANCE DIRECTIVE SHALL STILL BE VALID AND ENFORCEABLE. Once this directive is executed it cannot be changed or modified. If you want to make changes, you must make an entirely new directive. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR JUSTICE OF THE PEACE OR TWO (2) OR MORE QUALIFIED WITNESSES, WHO MUST BOTH BE PRESENT WHENYOU SIGNAND WHO WILL ACKNOWLEDGE YOUR SIGNATURE ON THE DOCUMENT. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES: The person you have designated as your health care agent; Your spouse or heir at law;
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Your attending physician or APRN, or person acting under the direction or control of the attending physician or APRN; ONLY ONE OF THE TWO WITNESSES MAY BE YOUR HEALTH OR RESIDENTIAL CARE PROVIDER OR ONE OF YOUR PROVIDERS EMPLOYEES.

DECLARATION and DURABLE POWER OF ATTORNEY FOR HEALTH CARE

I. DECLARATION Declaration made this _____ day of ____________________, _____. I, Dorian Mayhew Rothschild, 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: If at any time I should have an incurable injury, disease, or illness and I am certified to be near death or in a permanently unconscious condition by 2 physicians or a physician and an APRN, and 2 physicians or a physician and an APRN have determined that my death is imminent whether or not life-sustaining treatment is utilized and where the application of life-sustaining treatment would serve only to artificially prolong the dying process, or that I will remain in a permanently unconscious condition, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, the natural ingestion of food or fluids by eating and drinking, or the performance of any medical procedure deemed necessary to provide me with comfort care. I realize that situations could arise in which the only way to allow me to die would be to discontinue medically administered nutrition and hydration. In carrying out any instruction I have given under this section, I authorize that: medically administered nutrition and hydration not be started or, if started, be discontinued, _________ even if all other forms of life-sustaining treatment have been withdrawn, medically administered nutrition and hydration continue to be given to me.

(If this statement reflects your desires, you must initial the statement on the line provided.) 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. 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 physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. If any provision of this document is held to be invalid, such invalidity shall not affect the other
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provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable. I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. THIS LIVING WILL DIRECTIVE MUST BE SIGNED BY TWO WITNESSES OR A NOTARY PUBLIC OR A JUSTICE OF THE PEACE. Signed this _____day of ____________________________, 20_________.

___________________________________ Principal's Signature Name: Address: Dorian Mayhew Rothschild Humphrey Nearing County New Hampshire 123-45-6789 August 18, 1954

SSN: Birthdate:

[If you are physically unable to sign, this directive may be signed by someone else writing your name, in your presence and at your express direction.] II. DURABLE POWER OF ATTORNEY FOR HEALTH CARE DESIGNATION OF HEALTH CARE AGENT. I, Dorian Mayhew Rothschild, hereby appoint: Agent Name: Address: Phone: Relation, if any: Thomas Macky 35 Palm Circle Dr. Beaver, NH 75665 Home: 4157745543 Work: 4157743996 Friend

as my Agent to make any and all health care decisions for me, except to the extent I state otherwise in this document or as prohibited by law. My agent must act consistently with my desires as stated in this document or otherwise made known. This Durable Power of Attorney for Health Care shall take effect in the event I become unable to make my own health care decisions. RESTRICTIONS ON WHO MAY ACT AS AGENT A person may not exercise the authority of Agent while serving in one of the following capacities:
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1. The Principal's health care provider. 2. A nonrelative of the Principal who is an employee of the Principal's health care provider. 3. The Principal's residential care provider. 4. A nonrelative of the Principal who is an employee of the Principal's residential care provider. STATEMENT OF DESIRES, SPECIAL PROVISIONS AND LIMITATIONS REGARDING HEALTH CARE DECISIONS. (Life-sustaining treatment is defined as procedures without which a person would die, such as but not limited to the following: cardiopulmonary resuscitation, mechanical respiration, kidney dialysis or the use of other external mechanical and technological devices, drugs to maintain blood pressure, blood transfusions and antibiotics.) I give my Agent power to act in these specified circumstances. SUSTAINING TREATMENT. If I am near death and lack the capacity to make health care decisions, I authorize my agent to direct that life-sustaining treatment: not be started or, if started, be discontinued. _________ continue to be given to me.

(If this statement reflects your desires, you must initial the statement on the line provided.) Whether near death or not, if I become permanently unconscious I authorize my agent to direct that life-sustaining treatment: _________ not be started or, if started, be discontinued. continue to be given to me. (If this statement reflects your desires, you must initial the statement on the line provided.)

MEDICALLY ADMINISTERED NUTRITION AND HYDRATION. I realize that situations could arise in which the only way to allow me to die would be to not start or to discontinue medically administered nutrition and hydration. In carrying out any instructions I have given in this document, I authorize my Agent to direct that: _________ medically administered nutrition and hydration not to be started or, if started, be discontinued.

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even though all other forms of life-sustaining treatment have been withdrawn, medically administered nutrition and hydration continue to be given to me. (If this statement reflects your desires, you must initial the statement on the line provided.)

I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this directive. I have read and understand the information contained in the disclosure statement. 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. I understand the full import of this Durable Power of Attorney for Health Care and I am emotionally and mentally competent to make this Durable Power of Attorney for Health Care. THIS DURABLE POWER OF ATTORNEY MUST BE SIGNED BY TWO WITNESSES OR A NOTARY PUBLIC OR A JUSTICE OF THE PEACE. Signed this _____day of ____________________________, 20_________.

___________________________________ Principal's Signature Name: Address: Dorian Mayhew Rothschild Humphrey Nearing County New Hampshire 123-45-6789 August 18, 1954

SSN: Birthdate:

[If you are physically unable to sign, this durable power of attorney may be signed by someone else writing your name, in your presence and at your express direction.] State of New Hampshire County of _________________________ The foregoing instrument was acknowledged before me this _____ day of ____________________, _____, by Dorian Mayhew Rothschild. My Commission Expires: _________________________

________________________________________
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Notary Public/Justice of the Peace

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