DECLARATION and HEALTH CARE POWER OF ATTORNEY I.

DECLARATION
A. LIFE-SUSTAINING PROCEDURES. If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by the administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. B. NUTRITION. I DO desire that nutrition or hydration (food and water) be provided by gastric tube or intravenously if necessary. C. ORGAN DONATION. In the event of my death, I donate the following part(s) of my body for the purposes identified in AS 13.50.020: Tissues: any needed tissues. Organs: Heart, Kidney(s), Liver, Lung, Pancreas and any needed organs. Limitations: Use for transplantation only Notwithstanding the other provisions of this declaration, if I have donated an organ under this declaration or by another method, and if I am in a hospital when a do not resuscitate order is to be implemented for me, I do not want the do not resuscitate order to take effect until the donated organ can be evaluated to determine if the organ is suitable for donation. D. 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. E. OTHER REQUESTS. None

II. HEALTH CARE POWER OF ATTORNEY

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THE POWERS GRANTED FROM THE PRINCIPAL TO THE AGENT OR AGENTS TO MAKE YOUR HEALTH CARE DECISIONS IN THE FOLLOWING DOCUMENT ARE VERY BROAD. ACCORDINGLY, THE FOLLOWING DOCUMENT SHOULD ONLY BE USED AFTER CAREFUL CONSIDERATION. IF YOU HAVE ANY QUESTIONS ABOUT THIS DOCUMENT, YOU SHOULD SEEK COMPETENT ADVICE. YOU MAY REVOKE THIS POWER OF ATTORNEY AT ANY TIME. Pursuant to Alaska Statute 13.26.338 -- 13.26.353, I, Karla Espinoza, of Big City, Alaska, do hereby appoint: Agent Name: Address: Phone: Relation, if any: James Smith 25 Hayes St Big City, AL 99991 Home: 343-253-6785 Work: 343-145-2356 Cousin

my Attorney-in-Fact ("Agent") to act as I have indicated below in my name, place, and stead in any way which I myself could do, if I were personally present, with respect to the following matters, as each of them is defined in Alaska Statute 13.26.344, to the full extent that I am permitted by law to act through an Agent. This document shall become effective upon the date of my disability and shall not otherwise be affected by my disability. THE AGENT OR AGENTS YOU HAVE APPOINTED WILL HAVE ALL THE POWERS TO MAKE YOUR HEALTH CARE DECISIONS AND ARRANGE FOR HEALTH CARE SERVICES. Health care services shall be construed to mean that I authorize my Agent to make health care decisions on my behalf, to the fullest extent authorized by law, if I am unable to do so for myself, whether to be provided in the state or elsewhere. SPECIFIC PROVISIONS A. LIVING WILL. I have executed a separate declaration under AS 18.12, known as a "Living Will." B. MENTAL HEALTH TREATMENT. I have executed a separate declaration under AS 47.30.950 - 47.30.980 regarding mental health treatment. If I appointed an attorney-in-fact under AS 47.30.950 - 47.30.980, I authorize that attorney-in-fact and the attorney-in-fact whom I have appointed in the document to serve jointly with consent of each other as to my mental health treatment. C. LIMITATIONS ON THE DECISION-MAKING AUTHORITY OF MY AGENT: None
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D. ALTERNATE AGENT. YOU MAY DESIGNATE AN ALTERNATE AGENT. ANY ALTERNATE YOU DESIGNATE WILL BE ABLE TO EXERCISE THE SAME POWERS AS THE AGENT YOU NAMED AT THE BEGINNING OF THIS DOCUMENT. IF YOU WISH TO DESIGNATE AN ALTERNATE OR ALTERNATES, COMPLETE THE FOLLOWING: If the Agent named at the beginning of this document is unable or unwilling to serve or continue to serve, then I appoint the following Agent to serve with the same powers: First Alternate or Successor Agent: Agent Name: Address: Phone: Susan Allen 55 Orange St Wild City, AL 94902 Home: (555)343-1545 Work: (555)554-4567

E. GUARDIAN. YOU MAY NOMINATE A GUARDIAN OR CONSERVATOR. IF YOU WISH TO NOMINATE A GUARDIAN OR CONSERVATOR, COMPLETE THE FOLLOWING: In the event that a court decides that it is necessary to appoint a Guardian or Conservator for me, I hereby nominate Name: Address: Rose Black 65 5th St Apple City, AL 99021

to be considered by the court for appointment to serve as my Guardian or Conservator, or in any similar representative capacity.

III. GENERAL PROVISIONS

A. NOTICE OF REVOCATION OF THE POWERS GRANTED IN THIS DOCUMENT. You may revoke one or more of the powers granted in this document. Unless otherwise provided in this document, you may revoke all the powers granted in this power of attorney by completing a subsequent power of attorney. B. NOTICE TO THIRD PARTIES. A third party who relies on the reasonable representations of an Agent as to a matter relating to a power granted by a properly executed statutory power of attorney does not incur any liability to the Principal or to the Principal's heirs, assigns, or estate as a result of permitting the Agent to exercise the authority granted by the power of attorney. A third party who fails to honor a properly executed statutory form power of attorney may be liable to the
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Principal, the Agent, the Principal's heirs, assigns, or estate for a civil penalty, plus damages, costs, and fees associated with the failure to comply with the statutory form power of attorney. If the power of attorney is one which becomes effective upon the disability of the Principal, the disability of the Principal is established by an affidavit, as required by law. C. 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. D. 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 POWER OF ATTORNEY) 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:

________________________________________ Karla Espinoza Big City Apple County Alaska February 06, 1942

SSN: Birthdate:

Subscribed and sworn to or affirmed before me at ____________________, ____________________ on the _____day of ____________________, _____.

________________________________________ Signature of Officer or Notary

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