HEALTH CARE DECISIONS

(California Civil Code Sections 2410-2444)

By this document I intend to create a durable power of attorney by appointing the person designated below to make health care decisions for me as allowed by Sections 2410 to 2444, inclusive, of the California Civil Code. This power of attorney shall not be affected by my subsequent incapacity. I hereby revoke any prior durable power of attorney for health care. I am a California resident who is at least 18 years old, of sound mind and acting of my own free will.

I, ______________________, hereby appoint:

Name __________________________________________________________________

Address ________________________________________________________________

Work Phone ______________________ Home Phone ___________________________

As my agent (attorney-in-fact) to make health care decisions for me as authorized in this document and as reflected in my Uniform Living Will (Statement of Personal Desires) attached and dated ______________________. I understand that this power of attorney will be effective for an indefinite period of time unless I revoke it or limit its duration below.

(Optional) This power of attorney shall expire on the following date: _______________.

If I become incapable of giving informed consent to health care decisions, I grant my agent full power and authority to make those decisions for me, subject to any statements in my Uniform Living Will (Statement of Personal Desired) attached and dated ________________. Unless I have limited my agent's authority in this document or my Uniform Living Will, that authority shall include the right to consent, refuse consent, or withdraw consent to any medical care, treatment, service, or procedure; to receive and to consent to the release of medical information; to authorize an autopsy to determine the cause of my death; and to direct the disposition of my remains, subject to any instructions I have given in written contract for funeral services, my will, my Worksheet/Preplanner for the Services attached and dated _________________, or by some other method. I understand that, by law, my agent may not consent to any of the following: commitment to a mental health treatment facility, convulsive treatment, psychosurgery, sterilization or abortion.

If the person named as my agent in Paragraph II is not available or willing to make health care decisions for me as authorized in this document, I appoint the following persons to do so, listed in the order they should be asked:

First Alternate Agent: Name _____________________________________________

Address: _______________________________ Phone __________________________

Second Alternate Agent: Name _____________________________________________

Address: _______________________________ Phone __________________________

I hereby authorize that photocopies of this document can be relied upon by my agent and others as though they were originals.

VI.

I sign my name to this Durable Power of Attorney for Health Care Decisions at (City) _______________, (State) _________________, on this, the ____________ day of _______________, in the year of our Lord 199_____.

_________________________________

(Signature)

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, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, an employee of a health care provider, the operator of a community care facility or a residential care facility for the elderly, nor an employee of an operator of a community care facility or residential care facility for the elderly.

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 _________________________________

I further declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and am serving as a witness as required by subdivision (f) of Civil Code Section 2432.

Signature _____________________________

Name _______________________________

Date ________________________________

Address _____________________________

              ______________________________

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 _________________________________