{\rtf1\ansi\ansicpg1252\uc1\deff0\stshfdbch0\stshfloch0\stshfhich0\stshfbi0\deflang1033\deflangfe1033{\fonttbl{\f0\froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f36\froman\fcharset238\fprq2 Times New Roman CE;} {\f37\froman\fcharset204\fprq2 Times New Roman Cyr;}{\f39\froman\fcharset161\fprq2 Times New Roman Greek;}{\f40\froman\fcharset162\fprq2 Times New Roman Tur;}{\f41\froman\fcharset177\fprq2 Times New Roman (Hebrew);} {\f42\froman\fcharset178\fprq2 Times New Roman (Arabic);}{\f43\froman\fcharset186\fprq2 Times New Roman Baltic;}{\f44\froman\fcharset163\fprq2 Times New Roman (Vietnamese);}}{\colortbl;\red0\green0\blue0;\red0\green0\blue255;\red0\green255\blue255; \red0\green255\blue0;\red255\green0\blue255;\red255\green0\blue0;\red255\green255\blue0;\red255\green255\blue255;\red0\green0\blue128;\red0\green128\blue128;\red0\green128\blue0;\red128\green0\blue128;\red128\green0\blue0;\red128\green128\blue0; \red128\green128\blue128;\red192\green192\blue192;}{\stylesheet{\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 \snext0 Normal;}{\*\cs10 \additive \ssemihidden Default Paragraph Font;}{\*\ts11\tsrowd\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\trcbpat1\trcfpat1\tscellwidthfts0\tsvertalt\tsbrdrt\tsbrdrl\tsbrdrb\tsbrdrr\tsbrdrdgl\tsbrdrdgr\tsbrdrh\tsbrdrv \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1024\langfe1024\cgrid\langnp1024\langfenp1024 \snext11 \ssemihidden Normal Table;}}{\*\rsidtbl \rsid13181455}{\*\generator Microsoft Word 10.0.2627;}{\info{\title } {\author Bernard Hamill}{\operator Bernard J. Hamill}{\creatim\yr2002\mo1\dy28\hr14\min19}{\revtim\yr2002\mo1\dy29\hr18\min19}{\version4}{\edmins16}{\nofpages2}{\nofwords811}{\nofchars4627}{\*\company Hamill Law Offices}{\nofcharsws5428}{\vern16437}} \margl1440\margr1440 \widowctrl\ftnbj\aenddoc\noxlattoyen\expshrtn\noultrlspc\dntblnsbdb\nospaceforul\hyphcaps0\horzdoc\dghspace120\dgvspace120\dghorigin1701\dgvorigin1984\dghshow0\dgvshow3\jcompress\viewkind4\viewscale100\nolnhtadjtbl\rsidroot13181455 \fet0\sectd \pgnrestart\linex0\endnhere\titlepg\sectdefaultcl\sftnbj {\footer \pard\plain \qc \li0\ri0\widctlpar\tqc\tx4320\tqr\tx8640\faauto\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\field{\*\fldinst { \fs20\insrsid13181455 PAGE}}{\fldrslt {\fs20\lang1024\langfe1024\noproof\insrsid13181455 2}}}{\fs20\insrsid13181455 \par }}{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}} {\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8 \pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ql \li0\ri0\widctlpar\faauto\rin0\lin0\itap0\pararsid13181455 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\fs20\insrsid13181455 \par }\pard \qc \li0\ri0\widctlpar\faauto\rin0\lin0\itap0 {\b\fs20\ul\insrsid13181455 HEALTH CARE PROXY}{\fs20\insrsid13181455 \par }\pard \qj \li0\ri0\widctlpar\faauto\rin0\lin0\itap0 {\fs20\insrsid13181455 \par }{\b\fs20\insrsid13181455 TO:}{\fs20\insrsid13181455 My family, physicians and all \par those concerned with my care \par \par \tab \tab I, (YOUR NAME), presently residing at _______Street,(City or Town), MA. (zipcode), and being an adult of sound mind, pursuant to Massachusetts General Laws, Chapter 201D, hereby appoint and authorize (NAME OF YOUR HEALT H CARE AGENT), presently residing at (Health Agents Address), tel. no.:_______ , as my agent to act for me and in my name to make and communicate any and all decisions about or relating to my receipt or refusal to accept medical treatment, hospitalization , health care or personal care, in any situation in which, as the result of illness, disease, mental de\-terioration or injury, I am incapable of making or communicating a decision with respect to my treatment or care. This authoriza\- tion includes the right to refuse and direct the withdrawal of medical treatment which would prolong my life, and to communicate health care decisions to all persons including without limitation my physicians, health care providers and family. \par \par }{\b\fs20\insrsid13181455 NOTE: In the space provided below, insert any specific desires, special provisions or limitations which you desire:}{\fs20\insrsid13181455 \par \par \par \par \par \par \par \par \par \par \par \par \tab \tab I further delegate to my agent the power and authority to select, employ and discharge health care personnel, such as physicians, nurses, therapists, hospic e care and home health care providers, and other medical professionals; to admit or discharge me (including transfer from another facility) from any hospital, hospice, nursing home, adult home or other medical care facility; and to apply for public benefi t s to defray the cost of health care, and to contract in my name and on my behalf for all health care services, including without limitation medical, nursing and hospital care, as my agent may deem appropriate. I confirm that I shall be and remain persona lly liable for the payment of all such care and services to the same extent as if I had personally contracted therefor. \par \par \tab \{}{\b\fs20\insrsid13181455 OPTIONAL}{\fs20\insrsid13181455 \}\tab I authorize my agent to donate all or any part of my body for transplantation, therapy, advancement of medical or dental science, research, or other medical, educational or scien\- tific purpose, or to otherwise direct the disposition of my remains. \par \par \tab \tab I further authorize my agent to request, receive and review any information regarding my physical or mental health, including without limitation medical and hospital records; to execute on my behalf any releases or other documents that may be required in order to obtain this information; and to consent to the disclosure of this information. I authorize my agent to exe\- cute on my behalf any documents necessary or desirable to imple\- ment the health care decisions that my agent is authorized to make pursuant to this document, including without limitation all documents pertaining to a refusal to permit medical treatment, or authoriz ing the leaving of a medical facility against medical advice, or any waivers or releases from liability required by a physician or health care provider. \par \par \tab \tab I reserve the power to revoke this document at any time by communicating my intent to revoke in any manner in which I am able to communicate. \par \par \tab \tab The authority of my agent shall become effective when I can no longer make or communicate my own medical decisions. The determination of whether I can make or communicate my own medical decisions is to be m ade by my attending physician. I have read the foregoing notice concerning the legal consequences of my exe\-cuting this document. I have discussed my wishes with, and have carefully selected, my agent. \par \par \tab \tab }{\b\fs20\insrsid13181455 IN WITNESS WHEREOF}{\fs20\insrsid13181455 , I have executed this instrument, as my free and voluntary act and deed, this ________ day of ________, 2002. \par \par }\pard \ql \li3840\ri0\widctlpar\faauto\rin0\lin3840\itap0 {\fs20\insrsid13181455 \par __________________________ \par }\pard \ql \li4200\ri0\widctlpar\faauto\rin0\lin4200\itap0 {\fs20\insrsid13181455 YOUR NAME \par }\pard \qj \li0\ri0\widctlpar\faauto\rin0\lin0\itap0 {\fs20\insrsid13181455 \par WITNESS: \par \par \tab \tab We, (Witness #1) and ( Witness #2) , each hereby attest and declare under penalty of perjury under the laws of the Common\- wealth of Massachusetts that: (1) the foregoing instrument was personally signed by ( YOUR NAME) in my presence, and thereupon I, at his request a nd in his/her presence and in the presence of the other witnesses, have hereunto subscribed my name as a witness; (2) I did not sign the above signature of ( YOUR NAME) for or at his/her direction; (3) I personally know ( YOUR NAME) and believe him/her to be of sound mind and under no constraint, duress, fraud or undue in\- fluence; (4) I am not related to ( YOUR NAME) by blood, marriage or adoption; (5) I am not entitled (to the best of my knowledge and belief) to any portion of the estate of ( YOUR NAME) up on his/her death under any will or codicil or by operation of law; (6) I do not have any present or inchoate claim against any por\- tion of the estate of ( YOUR NAME); (7) I do not have any financial responsibility for the medical care of ( YOUR NAME); (8) I am not a physician or an employee of any physician, and I am not an oper\- ator or employee of, or patient in, any hospital, health care provider, residential care facility, community care facility or similar institution; (9) I am not a person named as agent in this instrument; and (10) I am at least 18 years of age. \par \par Dated: __________, 2002 \par }\pard \ql \li0\ri0\widctlpar\faauto\rin0\lin0\itap0 {\fs20\insrsid13181455 \par \par __________________________ \par }\pard \ql \li3840\ri0\widctlpar\faauto\rin0\lin3840\itap0 {\fs20\insrsid13181455 \par residing at \par }\pard \ql \li4800\ri0\widctlpar\faauto\rin0\lin4800\itap0 {\fs20\insrsid13181455 \par __________________________ \par \par __________________________ \par }\pard \ql \li0\ri0\widctlpar\faauto\rin0\lin0\itap0 {\fs20\insrsid13181455 \par \par __________________________ \par }\pard \ql \li3840\ri0\widctlpar\faauto\rin0\lin3840\itap0 {\fs20\insrsid13181455 \par residing at \par }\pard \ql \li4800\ri0\widctlpar\faauto\rin0\lin4800\itap0 {\fs20\insrsid13181455 \par __________________________ \par \par __________________________ \par }\pard \qj \li0\ri0\widctlpar\faauto\rin0\lin0\itap0 {\fs20\insrsid13181455 \par }\pard \ql \li0\ri0\widctlpar\faauto\rin0\lin0\itap0 {\fs20\insrsid13181455 \par }}