DECLARATION and DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS I.

DECLARATION
Declaration made this ______ day of ____________________, _____. I, Rose Espinoza, 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: A. STATEMENT OF DECLARANT. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition or a permanently unconscious condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized, or that I will remain in a permanently unconscious condition, and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care. B. NUTRITION AND HYDRATION. If I have a condition stated above, it is my preference TO RECEIVE artificially administered nutrition and hydration (food and fluids). C. PREGNANCY. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy. However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point. If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant. 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 physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

II. DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS

A. GENERAL STATEMENT OF AUTHORITY GRANTED. I, Rose Espinoza, designate

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and appoint: (Neither the treating health care provider, as defined by subsection (c) of K.S.A. 65-4921 and amendments thereto, nor an employee of the treating health care provider, nor an employee, owner, director or officer of a facility described in K.S.A. 1989 Supp. 58-629(a)(2) may be designated as the Agent to make health care decisions under a Durable Power of Attorney for Health Care Decisions unless: (1) Related to the Principal by blood, marriage or adoption; or (2) the Principal and Agent are members of the same community of persons who are bound by vows to a religious life and who conduct or assist in the conduct of religious services and actually and regularly engage in religious, benevolent, charitable or educational ministrations or the performance of health care services.) Agent Name: Address: Phone: Relation, if any: Jose Espinoza 25 Justice St San Rafael, KS 94901 Home: (415)435-34345 Work: (415)456-5554 Cousin

to be my Agent for health care decisions and pursuant to the language stated below, on my behalf to: a. Consent, refuse consent, or withdraw consent to any care, treatment, service or procedure to maintain, diagnose, or treat a physical or mental condition, including the withdrawal and withholding of artificially provided food and fluids, and to make decisions about organ donation, autopsy and disposition of the body; b. Make all necessary arrangements at any hospital, psychiatric hospital or psychiatric treatment facility, hospice, nursing home or similar institution; to employ or discharge health care personnel to include physicians, psychiatrists, psychologists, dentists, nurses, therapists or any other person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care as the Agent shall deem necessary for my physical, mental and emotional well being; and c. Request, receive and review any information, verbal or written, regarding my personal affairs or physical or mental health including medical and hospital records and to execute any releases or other documents that may be required in order to obtain such information. B. DESIGNATION OF ALTERNATE AGENT. If the person designated as my Agent is not available or unable to act, I designate the following persons to serve as my Agent to make health care decisions for me as authorized by this document, who serve in the following order:

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FIRST ALTERNATE AGENT Agent Name: Address: Phone: Sam Green 500 H st San Rafael, KS 94901 Home: (415)565-4545 Work: (415)666-5555

SECOND ALTERNATE AGENT Agent Name: Address: Phone: Willian Anki 35 Mission St San Rafael, KS 94901 Home: (415)454-4545 Work: (415)343-4545

C. LIMITATIONS OF AUTHORITY. 1. The powers of the Agent herein shall be limited to the extent set out in writing in this Durable Power of Attorney for Health Care Decisions, and shall not include the power to revoke or invalidate any previously existing declaration made in accordance with the natural death act. 2. The Agent shall be prohibited from authorizing consent for the following items: (none) 3. This Durable Power of Attorney for Health Care Decisions shall be subject to the additional following limitations: (none) D. EFFECTIVE TIME. This Power of Attorney for Health Care Decisions shall become effective immediately and shall not be affected by my subsequent disability or incapacity. This is a durable power of attorney and the authority of my attorney in fact shall not terminate if I become disabled or in the event of later uncertainty as to whether I am dead or alive. E. NOMINATION OF GUARDIAN. (According to Kansas law, if, following execution of this document, a court appoints a Guardian charged with the responsibility for your person, the Guardian will have the same power to revoke or amend this Durable Power of Attorney that you would have had if you were not disabled or incapacitated.) If a Guardian for my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian. F. REVOCATION. Any Durable Power of Attorney for Health Care Decisions I have previously made is hereby revoked. (This Durable Power of Attorney for Health Care Decisions shall be revoked by an instrument in writing executed, witnessed or acknowledged in the same manner as required herein or set out
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another manner of revocation, if desired.) This Durable Power of Attorney for Health Care Decisions may be revoked by me at any time and in any manner regardless of my mental or physical condition.

III. SEVERABILITY.
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. EXECUTION Executed this _____ day of ____________________, _____, at _________________________, _________________________.

Signature: Name: Address:

________________________________________ Rose Espinoza San Rafael Marin County Kansas February 06, 1942

SSN: Birthdate:

This document must be: (1) Witnessed by two individuals of lawful age who are not the Agent, not related to Rose Espinoza by blood, marriage or adoption, not entitled to any portion of Rose Espinoza's estate and not financially responsible for Rose Espinoza's health care; OR (2) acknowledged by a Notary Public. STATEMENT OF WITNESSES I declare that Rose Espinoza who signed or acknowledged this document (the "Principal") has identified himself or herself to me, that Rose Espinoza signed or acknowledged this document in my presence, that Rose Espinoza appears to be of sound mind and under no duress or undue influence. I did not sign Rose Espinoza's signature above for or at the direction of Rose Espinoza. I am not the person appointed as Agent or Alternate Agent by this document, nor am I a provider of health or residential care, an employee of a provider of health or residential care, the operator of community care facility, or an employee of an operator of a health care facility. I further declare that I am not related to Rose Espinoza by blood, marriage, or adoption, and to the best of my knowledge, I am not a creditor of Rose Espinoza or entitled to any part of the estate of Rose Espinoza under a Will now existing or by operation of law. I am not directly
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financially responsible for Rose Espinoza's health care. I am at least 18 years of age.

Witness Signature: Name: Address:

________________________________________ Sara Masonwood 56 D St San Rafael, KS 94901

Date: _________________________

Witness Signature: Name: Address:

________________________________________ Donald Grant 5553 Blue St San Rafael, KS 94901

Date: _________________________

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