HEALTHCARE POWER OF ATTORNEY ADVANCE HEALTHCARE DIRECTIVE OF RAY F.

KASTLE
I Ray F. Kastle of 1234 South Ct., SE, Salem Oregon create this advance healthcare directive to give instructions on my healthcare intentions, and if I am to become incapable of making medical decisions for myself. Unless revoked or suspended, this advance directive will continue for: INITIAL ONE: _______ My entire life _______ Other period (_______ Years) PART B: APPOINTMENT OF HEALTH CARE REPRESENTATIVE I appoint Chad E. Kastle, My Son, as my health care representative. My representatives address is 1234 South Ct., SE, Salem Oregon and telephone number is 503-364-1111. I appoint Kerri L. Kastle as my alternate health care representative. My alternates address is 1215 Sierra Morena Ct., Morgan Hill California. and telephone number 408-876-1111. I authorize my representative (or alternate) to direct my health care when I cant do so. NOTE: You may not appoint your doctor, an employee of your doctor, or an owner, operator or employee of your health care facility, unless that person is related to you by blood, marriage or adoption, or that person was appointed before your admission into the health care facility. PART B: APPOINTMENT OF HEALH CARE REPRESENTATIVE (CONTINUED) 1. Limits. Special Conditions or Instructions: There are no special Conditions or Instructions. INITIAL IF THIS APPLIES: _______ I have executed a Health Care Instruction or Directive to Physicians. My representative is to honor it. 2. Life Support. Life support refers to any medical means for maintaining life, including procedures, devices and medications. If you refuse life support, you will still get routine measures to keep you clean and comfortable. INITIAL IF THIS APPLIES: _______ My representative MAY decide about life support for me. (If you dont initial this space, then your representative MAY NOT decide about life support.) 3. Tube Feeding. One sort of life support is food and water supplied artificially by medical device, known as tube feeding. INITIAL IF THIS APPLIES: _______ My representative MAY decide about tube feeding for me. (If you dont initial this space, then your representative MAY NOT decide about tube feeding.) _______________________________ (Date) SIGN HERE TO APPOINT A HEALTH CARE REPRESENTATIVE __________________________________________________ Ray F. Kastle PART C: HEALTH CARE INSTRUCTIONS NOTE: In filling out these instructions, keep the following in mind: ADVANCED HEALTHCARE DIRECTIVE OF RAY F. KASTLE Page 1 of 4

 The term as my physician recommends means that you want your physician to try life support if your physician believes it could be helpful and then discontinue it if it is not helping your health condition or symptoms. Life support and tube feeding are defined in PART B above. If you refuse tube feeding, you should understand that malnutrition, dehydration and death will probably result. You will get care for your comfort and cleanliness, no matter what choices you make. You may either give specific instructions by filling out Items 1 to 4 below, or you may use the general instruction provided by Item 5. Here are my desires about my health care if my doctor and another knowledgeable doctor confirm that I am in a medical condition described below: 1. Close to Death. If I am close to death and life support would only postpone that moment of my death: A. INITIAL ONE: _______ I want to receive tube feeding. _______ I want tube feeding only as my physician recommends. _______ I DO NOT WANT tube feeding. B. INITIAL ONE: _______ I want any other life support that may apply. _______ I want life support only as my physician recommends. _______ I want NO life support. 2. Permanently Unconscious. If I am unconscious and it is very unlikely that I will ever become conscious again: A. INITIAL ONE: _______ I want to receive tube feeding. _______ I want tube feeding only as my physician recommends. _______ I DO NOT WANT tube feeding. B. INITIAL ONE: _______ I want any other life support that may apply. _______ I want life support only as my physician recommends. _______ I want NO life support.PART C: HEALTH CARE INSTRUCTIONS (CONTINUED) 3. Advanced Progressive Illness. If I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize my family and other people, and it is very unlikely that my condition will substantially improve: A. INITIAL ONE: _______ I want to receive tube feeding. _______ I want tube feeding only as my physician recommends. _______ I DO NOT WANT tube feeding. B. INITIAL ONE: _______ I want any other life support that may apply. _______ I want life support only as my physician recommends. _______ I want NO life support. 4. Extraordinary Suffering. If life support would not help my medical condition and would make me suffer permanent and severe pain: A. INITIAL ONE: _______ I want to receive tube feeding. _______ I want tube feeding only as my physician recommends. ADVANCED HEALTHCARE DIRECTIVE OF RAY F. KASTLE Page 2 of 4

_______ I DO NOT WANT tube feeding. B. INITIAL ONE: _______I want any other life support that may apply. _______I want life support only as my physician recommends. _______I want NO life support. 5. General Instruction. INITIAL IF THIS APPLIES: _______ I do not want my life to be prolonged by life support. I also do not want tube feeding as life support. I want my doctors to allow me to die naturally if my doctor and another knowledgeable doctor confirm I am in any of the medical conditions listed in Items 1 to 4 above. 6. Additional Conditions or Instructions. (Insert description of what you want done.) NoAdditionalInstructions__________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ PART C: HEALTH CARE INSTRUCTIONS (CONTINUED) 7. Other Documents. A health care power of attorney is any document you may have signed to appoint a representative to make health care decisions for you. INITIAL ONE: _______ I have previously signed a health care power of attorney. I want it to remain in effect unless I appointed a health care representative after signing the health care power of attorney. _______ I have a health care power of attorney, and I REVOKE IT. _______I DO NOT have a health care power of attorney. ___________________ (Date) SIGN HERE TO GIVE INSTRUCTIONS /s/_____________________________________ Signature of Ray F. Kastle NOTARYS ACKNOWLEDGEMENT State of Oregon ) ) ss: County of Marion ) Acknowledged before me, ________________________, a Notary Public, this 18th day of July 2011 by Ray F. Kastle, known to me (or proven on the basis of satisfactory evidence) to be such person and, who has acknowledged the said instrument to be his voluntary and lawful act and deed. __________________________SEAL; Notary Public for State of Oregon County of __________________ My commission expires: _________________

PART D: DECLARATION OF WITNESSES We declare that the person signing this advance directive: (a) Is personally known to us or has provided proof of identity; ADVANCED HEALTHCARE DIRECTIVE OF RAY F. KASTLE Page 3 of 4

(b) Signed or acknowledged that persons signature on the advance directive in our presence; (c) Appears to be of sound mind and not under duress, fraud or undue influence; (d) Has not appointed either of us as health care representative or alternative representative; and (e) Is not a patient for whom either of us is attending physician. Witnessed By: _______________________________________ _____________________________________ (Signature of Witness/Date) (Thomas Province) _______________________________________ _____________________________________ (Signature of Witness/Date) (Marilyn Province) NOTE: One witness must not be a relative (by blood, marriage or adoption) of the person signing this advance directive. That witness must also not be entitled to any portion of the persons estate upon death. That witness must also not own, operate or be employed at a health care facility where the person is a patient or resident.PART E: ACCEPTANCE BY HEALTH CARE REPRESENTATIVE I accept this appointment and agree to serve as health care representative. I understand I must act consistently with the desires of the person I represent, as expressed in this advance directive or otherwise made known to me. If I do not know the desires of the person I represent, I have a duty to act in what I believe in good faith to be that persons best interest. I understand that this document allows me to decide about that persons health care only while that person cannot do so. I understand that the person who appointed me may revoke this appointment. If I learn that this document has been suspended or revoked, I will inform the persons current health care provider if known to me. __________________________________________________________________ (Signature of Health Care Representative/Date) __________________________________________________________________ (Printed Name) __________________________________________________________________ (Signature of Alternate Health Care Representative/Date) __________________________________________________________________ (Printed Name)

ADVANCED HEALTHCARE DIRECTIVE OF RAY F. KASTLE

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