NOTICE: THIS IS AN IMPORTANT LEGAL DOCUMENT.

BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: (a) This document gives your health care providers or your designated Agent the power and guidance to make most health care decisions according to your wishes when you cannot do so. This document may include what kind of treatment you want or do not want and under what circumstances you want these decisions to be made. You may state where you want or do not want to receive any treatment. (b) This document will remain valid and in effect until and unless you amend or revoke it. Review this document periodically to make sure it continues to reflect your preferences. The Declarant may revoke this Health Care Proxy by notifying the Agent or a health care provider orally or in writing or by any other act evidencing a specific intent to revoke the Proxy. This Health Care Proxy shall also be revoked upon execution of a subsequent Health Care Proxy. (c) Your named Agent has the same right as you have to examine your medical records and to consent to their disclosure for purposes related to your health care or insurance unless you limit this right in this document. (d) If there is anything in this document that you do not understand, you should ask for professional help to have it explained to you.

HEALTH CARE PROXY

A. I, Dorian Mayhew Rothschild, hereby appoint: Agent Name: Address: Phone: Relation, if any: Mary Rothschild 60 Arthur St. New York, NY 50554 Home: (404) 459-1234 Work: (404) 596-9954 Wife

as my health care Agent to make any and all health care decisions for me, except to the extent I state otherwise. RESTRICTIONS ON WHO MAY BE A HEALTH CARE AGENT: - A physician shall not act as the Declarant's attending physician if serving as the Declarant's Agent, unless the physician declines the appointment as Agent. No physician affiliated with a mental hygiene facility or a psychiatric unit of a general hospital where the Declarant resides or is treated may serve as agent unless the physician is related to the Declarant by blood, marriage or adoption.
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- An operator, administrator or employee of a hospital may not be appointed as a health care Agent by any person who, at the time of the appointment, is a patient or resident of, or has applied for admission to, such hospital. This restriction shall not apply to the operator, administrator or employee of a hospital if he or she is related to the Declarant by blood, marriage or adoption. - No person shall serve as the health care Agent for more than ten Declarants unless the Agent is the spouse, child, grandchild, great grandchild, parent, brother, sister or grandparent of the Declarant. B. CREATION OF HEALTH CARE PROXY. This Health Care Proxy shall take effect in the event I become unable to make my own health care decisions. C. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, including the authority to direct the withdrawal and withholding of artificially administered food and fluids. In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. If my desires regarding a particular health care decision are not known to my Agent, then my Agent shall make the decision for me based upon what my Agent believes to be in my best interests. D. DURATION. I understand that, unless I revoke it, this Proxy will remain in effect indefinitely. E. DESIGNATION OF ALTERNATE AGENT. If the person appointed as my Health Care Agent is not reasonably available, willing and competent to serve as my Agent, and that person is not expected to become reasonably available, willing and competent to make a timely decision given my medical circumstances; or if the Agent is disqualified from acting on my behalf, I appoint as my Alternate Agent: FIRST ALTERNATE AGENT Agent Name: Address: Phone: Peter R. Olsen 123 Main St. New York, NY 50560 Home: (404) 321-3453 Work: (404) 153-1934

If, after my Alternate Agent's authority commences, the person appointed as Agent becomes available, willing and competent to serve as Agent, the authority of the Alternate Agent shall cease and the authority of the Agent shall commence. F. GENERAL PROVISIONS 1. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the
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terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them. 2. SEVERABILITY. 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. 3. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions. (YOU MUST DATE AND SIGN THIS HEALTH CARE PROXY IN THE PRESENCE OF TWO WITNESSES) I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration. Signed on _____ day of _______________, _____.

Signature: Name: Address:

________________________________________ Dorian Mayhew Rothschild San Rafael New York County New York 123-45-6789 April 04, 1957

SSN: Birthdate:

I declare that the person who signed or asked another to sign this document is personally known to me and appears to be of sound mind and acting willingly and free from duress. He or she signed (or asked another to sign for him or her) this document in my presence and that person signed in my presence. I am not the person appointed as Agent by this document. I am at least eighteen years old.

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Witness Signature: Name: Address:

________________________________________ Tom Mason 49 Bill St. New York, NY 50540

Date: _________________________

Witness Signature: Name: Address:

_________________________________________ Kailash Jeager 85 Providence Rd. Serras, NJ 50554

Date: ________________________

LIMITATIONS ON WHO MAY SERVE AS A WITNESS 1. Each witness must be at least eighteen years old. 2. The person appointed as Agent shall not act as witness to the execution of the Health Care Proxy. 3. If the Declarant resides in a mental hygiene facility operated or licensed by the office of mental health, at least one witness shall be an individual who is not affiliated with the facility, and if the mental hygiene facility is also a hospital as defined in subdivision 10 of section 1.03 of the mental hygiene law, at least one witness shall be a qualified psychiatrist. 4. For persons who reside in a mental hygiene facility operated or licensed by the office of mental retardation and developmental disabilities, at least one witness shall be an individual who is not affiliated with the facility and at least one witness shall be a physician or clinical psychologist who satisfies the requirements of the New York statute.

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