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REFUSAL TO DONATE ORGANS

I, Dorian Mayhew Rothschild, of 60 Arthur St., San Rafael, California 94901, refuse to donate any of my organs, tissues, or parts to be used for any purpose upon my death. I revoke any previous document or writing where I donated my organs, tissues, or parts to take effect on my death. 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.

Nondonor Signature:

__________________________________________ Dorian Mayhew Rothschild ___________________ February 10, 1952

Date Signed: Nondonor's Date of Birth:

I witnessed that this document was signed in my presence by the Nondonor. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:

Witness Signature:

__________________________________________ Ryan B. Jagger

Witness Signature:

__________________________________________ Peter R. Olsen

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