LIVING WILL and MEDICAL DURABLE POWER OF ATTORNEY I.

LIVING WILL
I, Sammy Espinoza, being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that: A. LIFE-SUSTAINING PROCEDURES If at any time my attending physician and one other qualified physician certify in writing that: If I, Sammy Espinoza, am in a terminal condition, or an irreversible coma (or a persistent vegetative state), that my doctors reasonably feel to be irreversible or incurable, I DO NOT want my life to be prolonged and I DO NOT WANT life-sustaining treatment, beyond comfort care, that would serve ONLY to artificially delay the moment of my death. B. ARTIFICIAL NOURISHMENT If I have a condition stated above, it is my preference that artificial nourishment shall not be continued. _______ (Declarant's initials) 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. D. CONSULT I hereby request that the following individuals be notified and given an opportunity to consult with my physician(s) prior to the withholding of any life-sustaining treatment. This request does not provide the named individuals with authority to override the decision of my physicians, only the opportunity to offer their opinions and input regarding my condition and circumstances: Name: Adrian Barbo Address: 13 Plum St
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City: Big City State: California Postal Code: 94901 Telephone Number: (415)435-4587 Cell Phone Number: (415)423-2345

II. MEDICAL DURABLE POWER OF ATTORNEY

A. DESIGNATION OF HEALTH CARE AGENT. I, Sammy Espinoza, of San Rafael, Colorado, appoint Agent Name: Address: Alicia Espinoza

13 Marin St Big City, CO 94901 Phone: Home: (415)345-8799 Work: (415)435-9192 Relation, if any: Cousin as my Agent to make health care and personal decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.

NOTICE: Generally you should not appoint any of the following persons as your Agent: 1. your treating physician or health care provider; 2. an employee of your physician or health care provider unless the person is your relative; 3. your residential care provider; or 4. an employee of your residential care provider unless the person is your relative. The term "health care" as used in this document includes all medical treatment, the provision, withholding or withdrawal of any health care medical procedure, including surgery, cardiopulmonary resuscitation, or service to maintain, diagnose, treat or provide for a patient's physical or mental health or personal care, unless such authority is otherwise limited by this document. B. CREATION OF MEDICAL DURABLE POWER OF ATTORNEY. By this document I intend to create a Durable Power of Attorney. This Durable Power of Attorney shall take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency. 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. My Agent has authority to direct the withdrawal and withholding of artificially provided food and fluids. In making any decision, my Agent shall attempt to discuss the proposed decision with me to determine my desires if I am able to communicate in any way.

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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. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS. I authorize my Agent, to the extent permitted by law, to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains. I hereby make an anatomical gift, to be effective upon my death, of any needed organs or tissues. E. 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: FIRST ALTERNATE AGENT Agent Name: Address: Phone: Jim Green 12 Sunny St Big City, CO 94901 Home: (415)453-7577 Work: (415)453-1119

SECOND ALTERNATE AGENT Agent Name: Address: Phone: Suzie Rose 314 Gold St Big City, CO 94901 Home: (415)435-2345 Work: (415)452-2211

F. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian.

III. GENERAL PROVISIONS

A. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the 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. B. 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.

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C. 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 DOCUMENT) 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: ________________________________________ Sammy Espinoza San Rafael Marin County Colorado February 06, 1942 STATEMENT OF WITNESSES The foregoing instrument was signed and declared by Sammy Espinoza to be his/her declaration, in the presence of us, who, in his/her presence, in the presence of each other, and at Sammy Espinoza's request, have signed our names below as witnesses, and we declare, that at the time of the execution of this instrument, Sammy Espinoza, according to our best knowledge and belief, was of sound mind and under no constraint, fraud, or undue influence. Sammy Espinoza is personally known to me. Neither of the witnesses is Sammy Espinoza's attending physician or any other physician, an employee of the attending physician or health care facility in which Sammy Espinoza is a patient, a person who has a claim against any portion of the estate of Sammy Espinoza at his/her death at the time the declaration is signed, or a person who knows or believes that he/she is entitled to any portion of the estate of Sammy Espinoza upon his/her death either as a beneficiary of a will in existence at the time the declaration is signed or as an heir at law. If Sammy Espinoza is a patient or resident of a health care facility, neither witness is a patient of that facility. Neither witness is a person appointed as Agent or Alternate Agent by this document. Neither witness is a provider of health or residential care or an employee of a provider thereof.

SSN: Birthdate:

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Witness Signature: Name: Address:

________________________________________ Julie Garcia 123 D St Big City, CO 94901

Date: ______________________________

Witness Signature: Name: Address:

_________________________________________ Arron Hunter 99 Glass St Big City, CO 94901

Date: ______________________________

State of _________________________, County of _________________________ ss: On this _____ day of _______________, _____, Sammy Espinoza, known to me (or satisfactorily proven) to be the person named in the foregoing instrument, personally appeared before me, a Notary Public, within and for the said State and County, and acknowledged that he/she freely and voluntarily executed the same for the purposes stated in the document. My commission expires: _____________________

_____________________________________ Notary Public

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