#15000
@001 State the name of the principal (person giving power):
@440 Enter the place of residence of the principal:
@441 State the name of the attorney:
@442 Enter the place of residence of the attorney:
#15047
@449 Enter the beginning date of the power of attorney:
@450 Enter the ending date of the power of attorney:
@003 Enter the state where signed:
@004 Enter the county where signed:
#end control section
#4400
/* 15000.arm--- Special poa for health care */


POWER OF ATTORNEY


@001, the "principal," of @440, herewith appoints @441
of @442, as their attorney in fact, to act in the place and
stead and with the same authority as Principal would have to
do the following acts:


In the event of my incapacity, to act in my place regarding any
and all health care decisions for me, including the type of
treatment, location of treatment, and in addition, the right
to refuse or decline life prolonging treatment and to direct
that any care which I receive be solely to alleviate pain.


My attorney shall have the power of substitution.


This is a durable power of attorney and shall not terminate upon
my incapacity.
#15047 /* Para. 15407: End of poa */


This power of attorney shall be in effect from @449 to @450.
However, should I be incapacitated or incompetent at the time
stated for expiration (@450), this power shall extend until
I am no longer incapacitated.


_____________________________________________________

@001, As Principal



STATE OF @003


COUNTY OF @004


@001 personally appeared before me and acknowledged
the execution of this power of attorney for the purposes set
forth therein.



Dated: _______________________________






__________________________________________

Notary Public