I, _____________________________________________________________________________

hereby appoint__________________________________________________________________
                                      (name, home address and telephone number)

____________________________________________________________________________________________
as my health care agent to make any and all health care decisions for me, except to the extent
that I state otherwise. This proxy shall take effect when and if I become unable to make my own
health care decisions.

Optional instructions: I direct my agent to make health care decisioins in accord with my
wishesand limitations as stated below, or as he or she otherwise knows. (Attach additional
pages if necessary.)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

(Unless your agent knows your wishes about artificial nutrition and hydration (feeding tubes),
your agent will not be allowed to make decisions about artificial nutrition and hydration. See
instructions for samples of language you could use.)

Name of substitute or fill-in agent if the person I appoint above is unable, unwilling or
unavailable to act as my health care agent.

_______________________________________________________________________________ 

_______________________________________________________________________________
                                             (name, home address and telephone number)

Unless I revoke it, this proxy shall remain in effect indefinitely, or until the date or conditions
stated below. this proxy shall expire (specific date or conditions, if desired):

_______________________________________________________________________________ 

Signature_______________________________________________________________________

Address________________________________________________________________________

Date___________________________________________________________________________

Statement by Witnesses (must be 18 or older)

I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence. 

Witness 1 ____________________________________________________________________________

Address  ___________________________________________________________________________

Witness 2 ___________________________________________________________________________

Address  __________________________________________________________________________