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California __________________________________ 4 Initials ______ ________________________ Print your name: ___________________________________ Address: __________________________________________ City: _____________________________________________ State: ___________erving as a witness as required by Section 4675 of the Probate Code. Date: _____________________________________________ Name: ____________________________________________ Sign your name _____________F PATIENT ADVOCATE OR OMBUDSMAN I declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and that I am sre and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign the following statement: STATEMENT OESS REQUIREMENT (5.1) The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that provides the following basic services: skilled nursing car her death under a will now existing or by operation of law. Signature of Witness: ___________________________________ Signature of Witness: ___________________________________ PART 5 - SPECIAL WITNted to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his oITIONAL STATEMENT OF WITNESSES: At least one of the above witnesses must also sign the following declaration: I further declare under penalty of perjury under the laws of California that I am not rela____________________________ Address: ___________________________________________ Signature of Witness: _________________________________ Date: ______________________________________________ (4.4) ADD_______________________________ Signature of Witness: _________________________________ Date: ______________________________________________ 3 Initials ______ SECOND WITNESS Name: _________________l care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly. FIRST WITNESS Name: _____________________________________________ Address: ____________th care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residentiaividual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as agent by this advance directive, and (5) that I am not the individual's healpersonally known to me, or that the individual's identity was proven to me by convincing evidence (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the ind________________ (4.3) STATEMENT OF WITNESSES: I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this advance health care directive is _ Print your name ______________________________________ Address ____________________________________________ City _______________________________________________ State _______________________________f this form has the same effect as the original. (4.2) SIGNATURE: Sign and date the form here: Date: ______________________________________________ Sign your name ____________________________________________________ City, State, Zip Code: ___________________________________________________ Phone: _______________________________________________________________ PART 4 (4.1) EFFECT OF COPY: A copy ophysician, I designate the following physician as my primary physician: Name of physician: _____________________________________________________ Address: ________________________________________________________ Phone: _______________________________________________________________ OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary ___________________________________________ Address: _____________________________________________________________ 2 Initials ______ City, State, Zip Code: _________________________________________t want): (1) Transplant (2) Therapy (3) Research (4) Education PART 3 - PRIMARY PHYSICIAN - (OPTIONAL) (3.1) I designate the following physician as my primary physician: Name of physician: __________ssues, or parts only: _________________________ _______________________________________________________________________ (c) My gift is for the following purposes (strike any of the following you do nosheets if needed.) PART 2 - DONATION OF ORGANS AT DEATH - (OPTIONAL) (2.1) Upon my death (mark applicable box): (a) I give any needed organs, tissues, or parts, OR (b) I give the following organs, tibove, you may do so here.) I direct that: ______________________________________________________________________ ______________________________________________________________________ (Add additional Add additional sheets if needed.) (1.3) OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given at be provided at all times, even if it hastens my death: ______________________________________________________________________ ______________________________________________________________________ (s possible within the limits of generally accepted health care standards. (1.2) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR (b) Choice To Prolong Life 1 Initials ______ I want my life to be prolonged as long a if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will noroviders and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below: (a) Choice Not To Prolong Life I do not want my life to be prolonged form at any time. PART 1 - INSTRUCTIONS FOR HEALTH CARE If you fill out this part of the form, you may strike any wording you do not want. (1.1) END-OF-LIFE DECISIONS: I direct that my health care p talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility. You have the right to revoke this living will or replace thisompleted form to your physician, to any other health-care provider you may have, to any health-care institution at which you are receiving care and to any health-care agents you have named. You shouldr health care. After completing this form, sign and date the form at the end. The form must be signed by two qualified witnesses or acknowledged before a notary public. Give a copy of the signed and crt 2 of this form lets you express an intention to donate your bodily organs and tissues following your death. Part 3 of this form lets you designate a physician to have primary responsibility for youwithdrawal of treatment to keep you alive, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. Pas you give specific instructions about any aspect of your health care, whether or not you appoint an agent. Choices are provided for you to express your wishes regarding the provision, withholding or donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form. Part 1 of this form letCALIFORNIA LIVING WILL (Based in part on California Probate Code Section 4701) You have the right to give instructions about your own health care. This form also lets you express your wishes regarding California