DURABLE POWER OF ATTORNEY FOR HEALTH CARE

A. DESIGNATION OF AGENT. I, Peter R. Olsen, of Miller, Missouri, appoint: Agent Name: Address: Phone: Relation, if any: Ryan B. Jagger 35 Palm Circle Dr. Vallen, MO 82876 Home: (405) 294-1234 Work: (405) 213-1123 Friend

as my Agent to make health care decisions for me if I am incapacitated and am unable to make my health care decisions. NOTICE: Your attending physician or an employee of your attending physician, or an owner, operator or employee of a health care facility in which you are a resident, shall not serve as your Attorney-in-Fact unless: (1) You are related by affinity or consanguinity within the second degree; or (2) You are members of the same community of persons who are bound by vows to a religious life and who conduct or assist in the conducting of religious services and actually and regularly engage in religious, benevolent, charitable, or educational ministry, or the performance of health care services. B. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care. This Power of Attorney shall take effect upon my incompetency and shall not terminate if I become disabled. C. AGENT'S POWERS. 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's authority shall include, but is not limited to, the authority to: 1. Give consent to, prohibit or withdraw any type of health care, medical care, treatment or procedure, even if my death may result, BUT NOT INCLUDING THE AUTHORITY TO DIRECT A HEALTH CARE PROVIDER TO WITHHOLD OR WITHDRAW ARTIFICIALLY SUPPLIED NUTRITION AND HYDRATION (INCLUDING TUBE FEEDING OF FOOD AND WATER). (WRITE YOUR INITIALS ON THE LINE TO THE RIGHT.)

___________________ INITIALS

This is a RocketLawyer.com Legal Document

2. Making all necessary arrangements for health care services on my behalf, and to hire and fire medical personnel responsible for my care; 3. Moving me into or out of any health care facility (even if against medical advice to obtain compliance with the decisions of my Agent; and 4. Taking any other action necessary to do what I authorize here, including (but not limited to) granting any waiver or release from liability required by any health care provider, and taking any legal action at the expense of my estate to enforce this Durable Power of Attorney. 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. My Agent shall seek and consider information concerning my medical diagnosis, the prognosis and the benefits and burdens of treatment. D. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS. I do not authorize my Agent to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains. E. AGENT'S FINANCIAL LIABILITY AND COMPENSATION. My Agent acting under this Durable Power of Attorney will incur no personal financial liability. My Agent shall not be entitled to compensation for services performed under this Durable Power of Attorney, but my Agent shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provision hereof. F. EFFECTIVE DATE AND DURABILITY. The Durable Power of Attorney is effective when TWO physicians decide that I am incapacitated and unable to make and communicate a health care decision. G. GENERAL PROVISIONS. 1. REVOCATION. This document may be revoked at any time and in any manner by which I am able to communicate the intent to revoke. Revocation shall be effective upon communication of such revocation to my Agent or to my attending physician or health care provider. 2. PROTECTION OF THIRD PARTIES WHO RELY ON MY AGENT. No person who relies in good faith upon any representations by my Agent or Alternate Agent shall be liable to me, my estate, my heirs or assigns, for recognizing the Agent's authority. 3. VALIDITY AND SEVERABILITY. This document is intended to be valid in any jurisdiction in which it is presented. The provisions of this document are separable, so that the invalidity of one or more provisions shall not affect any others. A copy of this document shall be as valid as the original. 4. 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
This is a RocketLawyer.com Legal Document

any health care decisions should be made on my behalf during any period in which I am unable to make such decisions. YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF TWO WITNESSES AND IN THE PRESENCE OF A NOTARY PUBLIC. IN WITNESS WHEREOF, I have executed this document this _____ day of ____________________, _____.

Signature: Name: Address:

________________________________________ Peter R. Olsen Miller Paloma County Missouri 123-45-6789 May 17, 1978

SSN: Birthdate:

The person who signed this document is of sound mind and voluntarily signed this document in our presence. Each of the undersigned witnesses is at least eighteen years of age and did not sign this document on behalf of or at the direction of Peter R. Olsen.

Witness Signature: Name: Address:

________________________________________ Dorian M. Rothschild 45 Billing St. Carlville, MO 82412

Date: _________________________

Witness Signature: Name: Address:

________________________________________

Mary Rothschild 45 Billing St. Carlville, MO 82412 Date: _________________________

This is a RocketLawyer.com Legal Document

STATE OF MISSOURI COUNTY OF _________________________ On this _____ day of _______________, _____, before me personally appeared Peter R. Olsen, to me known to be the person named in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County of _________________________, State of Missouri, the day and year first above written. My Commission Expires: ___________________________________

________________________________________ Notary Public

This is a RocketLawyer.com Legal Document