DURABLE HEALl

AND HEAtTIIC IICARE POWER OF A 1TORNEY

ARE TREATMENT INSTRUCTION S
PAW - D ~ (LIVING WILL)
\ C 'f M E:ok ~\ BLE IIEALTHCARE POWER oi· ATTORNEY
I, l\o\ r- \~~,o \ 6(i s t~of~-f-Ll.~w. ..:...:...t.~~-Co unty, Pennsylvania, appoint th
person named r,clo\\ ~o be 01Y agent to mal'.d health and personal ca e ecisions for me when and only when
lack sufficient capacJt~r to nui~e. or communicate a choice regarding a health or personal care decision a:
,·crified by n1y atteodang phys ician. My agent may not delegate the authority to make decisions.
l\fi1 AGENT HAS ALL OF THE J?OLLOWING POWERS (SUBJECT TO THE HEALTHCARI
TREADfENT INSTRUCTIONS THAT FOLLOW IN PART II):
1. To authorize, withhold or wit!1draw medic~l _care and surgical procedures;
2. ?
To authorize, withhold or Withdraw 0 tr•~•on (food) or hydratio_!l (w~r) medically suppliec
by tube ~}Jrough my nose, stoma~h, intestines or veins; ~t::,-
3. To authorize my admission to or dtsch~rge f~om a medical, nursing, residential or similar facilit)
and to make agreements for my care, tnclu~ing hospice care;
4. To have full access to my medical and hospital records and all information regarding my physica
or mental health~
5. To hire and fire medical, social service and other support personnel responsible for my care;
6. To take any legal action necessary to do what I have directed.
APPOINTMENT OF AGENT
I appoint the fallowing agent: r' \ \
At \
'f)
Agent: Ke
V:tfr )/o tJ t;..C. R TI J) f . , ~
(Naine and relati •)
?,o ,- <jl,(- • Address: l.\70\ \)); \ h1n. :Bue, Jc 13:r.-J- J JS'' (h.eu~r
1~~S (() Telephone Number: Home 3!.f-'tf,1#713 Wo 202 ~Yl-~ z~j-J V>~
You are not required ta appoint an agent. l.J you don't wish to appoint an agent, write "None" in the above space.
q you don't name an agent, health ca:e providers will ask your family for help in determining your wishes for
!r~-'ill-7'1' -1) Cc~) 3 6 \-98~-715~0'1) dad-- qi-[ d--'1. l YS-cw_)
If my agent is not available or if my agent is my spouse and becomes divorced from me after the date of this
document, I appoint the person or persons named below in the order named. (It is helpful, but not required, to

L
name alternative agents.)
First Alternative Age~t: J Second Alternative Age~t: L
Ve\j ei.s A To D (v\ Q&Or--' ---rto,f\~ ))/j'fl E: ,;,_Itf!"VK
,(}( (Natne and relationship) (Name and relationship)
V\ Address:\~\\ Lis.{ 14, fu,,h f a? f( 2,U, Address: U, II i N5 Au t 1 fV/1 .,,; f J..,.
Tel. No.: Home____ o r , Tel. No.: Home 3gs:', 'jL1 •$<> Work
,a~- 7ea5-f 6~ /
)
PART Il •• AJ4THCARE TREATMENT INSTRUCTIONS 3os'- W<-1-S's'«o
(LIVING WILL)
The following healthcare treatment instructions exercise my right to make decisions concerning my health
care. These instructions are intended to provide clear and convincing evidence of my wishes to be followed
when I lack the capacity to make or communicate my treatment decisions:

TERMINAL ILLNESS OR PE~m~is &oUSNE Ss

H I suffer from a te11nma1 eAAdllllR a a state of permanent unconacloUlllell coma
or persistent vegetative state and th WIiie of ply:
1. I direct that I be gi such
treatment might sh forming;
2. I direct that all life
3. I specifically d heart-lung
resuscitation ( machine)'
surgery, chem
 '
I ..
uvv/~V.f .
easeindicate whether you want .nu~ition (food) or hydranon (water) medically s;p;i;}d /Jra tube into your
(Hef'minal e9fttiitton or a state of permanent
no~e, stomach, intestine o_r veins if 1ou suffer .f~~:fcant
s . w· usness and there 1s no realistic hope of sig recovery. (lllitial only one statement.)
unconsc iUBE FEEDINGS ;1 •

•
1want tubefeedings to be given· tJ¼
~:e:
\.-- G'fr.J 0r 1 2, t Jn~ d'I\
-~- \-( r-- - NO'fUBEfE~DlNG~ P'j
1,--" l do not want tube feedings to be gi • / V- ,~
~ltl6~ (Mt Vf)
OTHER EXTREME ~OND~TIONS raill ,l:!s~a~ wiih no realistic hope of significan
If I should s~ffer from 1rrev~r~1bl~ bram damage ~r ; _t recov~ry,
1. woul d consider health care providers and agent to tre~t any mtervenmg
such a cond1t1on intolerable
and l w_ant my d'f state of permanent unconsc10usness as I have
~ife~lh.reatening conditions just a~ y would a tenm
md1cated above. nal con 1 ion or
\ Jr:
lt1~t~a1sj. Vr I agree
Initials _ _ _ _ _ I disagree
GOALS ~OPTl9NAL)
uvt: /'Rt'\!~ .
~:1 ~Jo ~~~ i:~c al decisions ifl from a-tetmimd Uh~rfJr other e~treme irre~~rfus 0ndi
«M. <hJ<" C. you,- pers on i r es su comfort i~~~i:~~~-f. -
care, preservation o1men a '
No o.d1 -~ . i::> ~s rs ;u MW 00wc.u;to.J., x~nr1 i:
. Vi (CA ) 1\0 pm Fla ~q: '"<-
LO t,d VJ d:::o C,~i.J J.Q ttl \/
AGE N't~ ~US E OF INS TRU CTI ONS (Init
- ~______.'.:.
•
M
y agen t
ial .
i':t
one option
follow these instructio~s.
only ) Ver
These inst~ ction s.are only gujdance. My agen
If I did not a oi t shall have final say, and inay override
any of my 1!15tructions. /
PP nt an agent, these instructions shall be foil
LEGAL PROTECTION d
owe •
On beha lf of mys elf m
rele ase and inde nini f •
executo_rs and heirs_ I hold
treat men t instr uctio n ¥ emdafg~inst any claim my agents and my health care ~roviders harm
le_ss, and
s 1n goo a1th. for reco gnizing my~ge_l!t__s' auth onty or for following
\~'1 £' my
SIGNATURE • I 3 °K
!~:tg c~fu lly_ readhth~~ d0c1nnent, I have sig d
ng prev ious . ealth crue povl:~;1,6f
it this day of A:uq U5 ±= , 20 0 l( ,
"""Y and medical treatment instructlons.
TT"'...

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~----~Pk:J.'H,£.
( • (SIG N ~!?UL --.::::..
'Al~E HERE FOR HEA.LTH
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CARE POWER OF ATTORN EY
/J ) A.ND HEALTHCARE TREATMEN INSTRUC TIONS)
A WITNESS:-'---'-::--~-,~-;_-+----,.--1---__:_f:-
U_ WIT NES S:t- µ~~ ~~I ',~~' J:.. AJ ---
l Two witnesses at least 1 ye rs ge are required in Pennsylvania and should witness
other's presence. (It is pre erab e if the witnesses you ignature in each
are not your heirs nor your creditors, nor employed
L your health care providers.) by any of
tJ
l
NOTARIZAT
ION (OPTIONAL)
(Notarization of document is not required in Penn
sylvania, but if the document is both witnessed and
more likely to be Jwrwred in some other states. J notarized, it is
On this __ _ day of _ _ _ _ _ _ _ _ _, 20_ _ _, before me personally appe
declarant, to me known to be the person ar~d the aforesaid
described in and who executed the foregoing
and acknowledged that he/she executed the instrument
same as his/her free act and deed. IN WITNES
I have hereunto set my hand and affixed my S WHEREOF,
official seal in the County of _ _ _ _ _
_ _ _ _ _ _ _ _ __, the day and year first _ _., State of
above written.

Notary Public My commission expires

1993, Allegheny County Bar Association/Allegheny County
Medical Society