S.B. 664                                                         VETOES

THE DECLARANT SIGNED OR ACKNOWLEDGED SIGNING THIS APPOINTMENT
OF A HEALTH CARE AGENT IN MY PRESENCE AND BASED UPON MY PERSONAL
OBSERVATION THE DECLARANT APPEARS TO BE A COMPETENT INDIVIDUAL.

(SIGNATURE OF TWO WITNESSES OR A NOTARY PUBLIC)

(WITNESS)                                                                                     (WITNESS)

SIGNATURE OF TWO WITNESSES

PART B

ADVANCE MEDICAL DIRECTIVE

HEALTH CARE INSTRUCTIONS

(OPTIONAL FORM)

(CROSS THROUGH IF YOU DO NOT WANT TO COMPLETE THIS PORTION OF THE
FORM. IF YOU DO WANT TO COMPLETE THIS PORTION OF THE FORM, INITIAL THOSE
STATEMENTS YOU WANT TO BE INCLUDED IN THE DOCUMENT AND CROSS
THROUGH THOSE STATEMENTS THAT DO NOT APPLY.)

IF I AM INCAPABLE OF MAKING AN INFORMED DECISION REGARDING MY HEALTH
CARE, I DIRECT MY HEALTH CARE PROVIDERS TO FOLLOW MY INSTRUCTIONS AS
SET FORTH BELOW. (INITIAL ALL THOSE THAT APPLY)

A. 1. IF I AM IN MY DEATH FROM A TERMINAL CONDITION IS IMMINENT, AND,
DESPITE THE APPLICATION OF EVEN IF LIFE-SUSTAINING PROCEDURES ARE USED,
THERE IS NO REASONABLE EXPECTATION OF MY RECOVERY -

[ ] ₌₌₌ I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE PROLONGING
LIFE-SUSTAINING PROCEDURES, INCLUDING THE ARTIFICIAL ADMINISTRATION OF
NUTRITION AND HYDRATION ARTIFICIALLY THROUGH TUBES.

[ ] ₌₌₌ I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE PROLONGING
LIFE-SUSTAINING PROCEDURES, EXCEPT THAT IF I AM UNABLE TO TAKE IN FOOD
BY MOUTH, I WISH TO RECEIVE NUTRITION AND HYDRATION THROUGH TUBES
ARTIFICIALLY.

B. 2. IF I AM IN A PERSISTENT VEGETATIVE STATE, THAT IS IF, IF I AM NOT
CONSCIOUS AND AM NOT AWARE OF MY ENVIRONMENT OR ABLE TO INTERACT
WITH OTHERS, AND THERE IS NO REASONABLE EXPECTATION OF MY RECOVERY -

[ ] ₌₌₌ I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE PROLONGING
LIFE-SUSTAINING PROCEDURES, INCLUDING THE ARTIFICIAL ADMINISTRATION OF
NUTRITION AND HYDRATION ARTIFICIALLY THROUGH TUBES.

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