____________________________

To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to be. To any individual who may become responsible for my health, welfare or affairs.

Death is as much a reality as birth, growth, maturity, and old age--it is the one certainty of life. If the time comes when I can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes while I am still of sound mind.

(The following paragraphs may be added to this document by initialing one or more.)

If the situation should arise in which I am in terminal state and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I do, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life. If this statement reflects your desires, initial here: ______

If it is permissible under the laws of the jurisdiction in which I may be hospitalized, I direct that the physicians supervising my care upon a terminal diagnosis to discontinue intravenous hydration (water) should the continuation of same be judged to result in unduly prolonging a natural death. If this statement reflects your desires, initial here: _______

If it is permissible under the laws of the jurisdiction in which I may be hospitalized, I direct that the physicians supervising my care upon a terminal diagnosis to discontinue feeding through a gastro-nasal tube should continuation of same be judged to result in unduly prolonging a natural death. If this statement reflects your desires, initial here: _______

This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that those to whom this will is addressed will regard themselves as morally bound by these provisions.

I herewith release any and all hospitals, physicians, and others both for myself and for my estate from any and all liability for complying with this declaration, to the fullest extent provided by law.

I herewith authorize my spouse, if any, or any relative who is related to me within the third degree to effectuate my transfer from any hospital or other health care facility in which I may be receiving care should that facility decline or refuse to effectuate the instructions given herein.

Signed this _______ day of ______________ in the year of our Lord 199_____.

___________________________________

Name ______________________________

Street address ________________________

City ________________________________

County _____________________________

State _______________________________

Social Security Number _________________

This document will be valid when it is signed and witnessed by two witnesses or by a Notary Public of and for California.

I declare under penalty of perjury under the laws of California that the person who signed or acknowledged this document is personally known to me to be the principal, or that the identity of the principal was proved to me by convincing evidence, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence.

Signature _________________________________

Name ___________________________________

Date ____________________________________

Address _________________________________

              _________________________________

Signature _________________________________

Name ___________________________________

Date ____________________________________

Address _________________________________

              _________________________________

At least one of the above witnesses must also sign the following declaration.

I further declare under penalty under the laws of California that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

Signature _________________________________

COUNTY OF FRESNO

On this, the __________ day of _______________ in the year of our Lord 199____, before me, ___________________________________________, personally appeared ______________________________________ personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it, I declare under penalty of perjury that the person whose name subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence.

_________________________________

(Signature of Notary Public)

My commission expires _________________________________