To Any Physician Who Is Treating Me, this document contains the following:

1. My Living Will or Health Care Instructions
2. My Appointment of A Health Care Agent
3. My Appointment of An Attorney-in-Fact For Health Care Decisions
4. The Designation of My Conservator Of The Person For My Future Incapacity
5. My Document of Anatomical Gift

As my physician, you may rely on any information provided by my health care agent and decisions made by my attorney-in-fact for health care decisions or conservator of my person, if I am unable to make a decision for myself.

If the time comes when I am incapacitated to the point when I can no longer actively take part in decisions for my own life, and am unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes.

I, ________________________________, the author of this document, request that, if my condition is deemed terminal or if I am determined to be permanently unconscious, I be allowed to die and not be kept alive through life support systems. By terminal condition, I mean that I have an incurable or irreversible medical condition which, without the administration of life support systems, will, in the opinion of my attending physician, result in death within a relatively short time. By permanently unconscious I mean that I am in a permanent coma or persistent vegetative state which is an irreversible condition in which I am at no time aware of myself or the environment and show no behavioral response to the environment.

          Specific Instructions

Listed below are my instructions regarding particular types of life support systems. This list is not all-inclusive. My general statement that I not be kept alive through life support systems provided to me is limited only where I have indicated that I desire a particular treatment to be provided.

Other specific requests:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

I do want sufficient pain medication to maintain my physical comfort. I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.

I appoint ______________________________________ to be my health care agent and my attorney-in-fact for health care decisions. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions and unable to reach and communicate an informed decision regarding treatment, _______________________________ is authorized;

          As My Health Care Agent to:

1. Convey to my physician my wishes concerning the withholding or removal of life support systems;

2. Take whatever actions are necessary to ensure that any wishes are given effect;

          As My Attorney-In-Fact to:

1. Act in my name, place and stead in any way which I myself could do, if I were personally present, with respect to health care decisions as defined in the Connecticut Statutory Short Form Power of Attorney Act to the extent that I am permitted by law to act through an agent;

2. Consent, refuse or withdraw consent to any medical treatment other than that designed solely for the purpose of maintaining physical comfort, withdrawal of life support systems, or withdrawal of nutrition or hydration.

If ________________________ is unwilling or unable to serve as my health care agent and my attorney-in-fact for health care decisions, I appoint ____________________________________ to be my alternative health care agent and my attorney-in-fact for health care decisions.

I give: (check one)

____________________ (1) any needed organs or parts
____________________ (2) only the following organs or parts

_________________________________________________________________________________________
_________________________________________________________________________________________

to be donated for: (check one)

____________________ (1) any of the purposes stated in subsection (a) of section 19a-279f of the
                                              general statutes
____________________ (2) these limited purposes _______________________________________.

If a conservator of my person should need to be appointed, I designate ________________________, be appointed my conservator. If _________________________ is unwilling or unable to serve as my conservator, I designate ____________________________. No bond shall be required of either of them in any jurisdiction.

These requests, appointments, and designations are made after careful reflection, while I am of sound mind. Any party receiving a duly executed copy or facsimile of this document may rely upon it unless such party has received actual notice of my revocation of it.

Date _______________, 200____                              x__________________________________L.S.

STATE OF CONNECTICUT                                     )
                                                                                    :     ss. _________________________________
COUNTY OF __________________________        )                                       (Town)

Personally appeared ____________________________, signer of the foregoing instrument, and acknowledged the same to be his/her free act and deed, before me, this _________ day of _________________________, 200____.

                                                                                                                                                                                                                                                                          _____________________________

                                                                                                      Commissioner of the Superior Court
                                                                                                      Notary Public
                                                                                                      My Commission expires: _________

This document was signed in our presence by _____________________________ the author of this document, who appeared to be eighteen years of age or older, of sound mind and able to understand the nature and consequences of health care decisions at the time this document was signed. The author appeared to be under no improper influence. We have subscribed this document in the author's presence and at the author's request and in the presence of each other.

x__________________________                                                   x___________________________
(Witness)                                                                                          (Witness)

x__________________________                                                   x___________________________
(Number and Street)                                                                         (Number and Street)

x__________________________                                                   x___________________________
(City, State and Zip Code)                                                               (City, State and Zip Code)

(NOTE: This Form is Optional)

STATE OF CONNECTICUT                                        )
                                                                                        :           ss. __________________________
COUNTY OF ____________________________        )                                 (Town)

We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of these health care instructions, the appointments of a health care agent and an attorney-in-fact, the designation of a conservator for future incapacity and a document of anatomical gift by the author of this document; that the author subscribed, published and declared the same to be the author's instructions, appointments and designation in our presence; that we thereafter subscribed the document as witnesses in the author's presence, at the author's request and in the presence of each other; that at the time of the execution of said document the author appeared to us to be eighteen years of age or older, of sound mind, able to understand the nature and consequences of said document, and under no improper influence, and we make this affidavit at the author's request this _____ day of ______________________, 200____.

x_____________________________                                           x____________________________
(Witness)                                                                                       (Witness)

x_____________________________                                           x____________________________
(Number and Street)                                                                       (Number and Street)

x_____________________________                                           x____________________________
(City, State and Zip Code)                                                             (City, State and Zip Code)

Personally appeared ____________________________, signer of the foregoing instrument, and acknowledged the same to be his/her free act and deed, before me, this ______ day of _________________________, 200____.

                                                                                                                                                                                                                                                                 __________________________________
                                                                                              Commissioner of the Superior Court
                                                                                              Notary Public
                                                                                              My Commission expires: _____________