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HomeMy WebLinkAbout02-19-10Pa. O.C. Rule 6.12 STATUS REPORT REGISTER OF tiVILLS OF ~'(,t Nd ~o~~-~ COUNTY, PENNSYLVANIA -r ~,!- Name of Decedent: ~~ V e ~ Y /V ~ ~ ~ U ((~ 1 ~ d ~ G~ Date of Death: rC~ 02 ~P ~ ~ File Number: ~ D~~ ~ ~ °l Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of the above-captioned estate: State whether administration of the estate is complete :................... es ~ No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is YES, state the following: a. Did the personal representative file a final account with the Court? ....... Yes ~ 1"" b. The separate Orphans' Court No. (if any) for the personal representative's account is: Did the personal representative state an account informally to the parties in interest? ............................... es ~ No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts maybe filed with the Clerk of the Orphans' Court and ma be attached to this report. ~rtte ~ /D ~ ki_ ~-- ; ,, ,~ f"7 C'~L Signature ojPerson Filing this Form l.a..i ~._' d ~ ` ~-=' _' _ `~~ Capacity: ersonal Representative Q Counsel i.~_ 7C ti..~'}C. ~~. ~ -' ~ -"' ~_ ~ Name o Person Filing this Forrn ~ :.. t :,_~ Lt. 7~77(~Cv~fs~35~ Telephone TDC~ DEPARTN83NT OF THE TREASURY IATI'SRNAL REVENUE SERVICE CINCINIIQATI OH 45999-0023 CfiARLOTTE E STEWART ESTATE DAVID C GUSSIE ADM 8 EDGEWOOD DR MECHANICSBURG, PA 17055 Date of this notice: 02-20-2009 Employer Identification Number: 26-6788130 Form: SS-4 Number of this notice: CP 575 B For assistance you may call ua at: 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIG3dED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN). We assigned you EIN 26-6788130. This EIN will identify your estate or trust.. If you are not the applicant, please contact the individual who is handling the estate or trust for you. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your SIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. if the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. Based on the information received from you or your representative, you must file the following form(s) by the date(s) shown. Form 1041 04/15/2010 If you have questions about the form(s) or the due date(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year), see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue). Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. To obtain tax forms and publications, including those referenced in this notice, visit our Web site at www.irs.gov. If you do not have access to the Internet, call 1-800-829-3676 (TTY/TDD 1-800-829-4059) or visit your local IRS office. n~~~~~~~~~~~i~~l~ i~ ' OFFICE OF FEDERAL EMPLOYEES' GROUP LIFE INSURANCE STATEMENT OF CLAIM PAYMENT FOR LIFE INSURANCE Claim Number 20070100658 Name of Payee Date of Death and/ or Dismemberment 10-26-2006 David Gussie Admin of th Group Number 0017000 Date of Birth 03-31-1916 Life Insurance Name of Insured C EVELY STEWART Interest Total $ 3575.61 $ 3500.00 ~ $ 75.61 THE OFFICE OF FEDERAL EMPLOYEES' GROUP LIFE INSURANCE CANNOT ASSIST YOU IN NEGOTIATING THE CHECK. YOU SHOULD CONTACT YOUR LOCAL BANK IN YOUR COMMUNITY. DATE: 02-18-2009 We withheld 28$ of the interest amount. 'his amount is We did not have the tax identification number for the insured'S29.40. estate/trust. You must first give us the tax identification number. You can request a refund of the interest amount withheld only from the IRS (not from OFEGLI) when you file your individual or estate income tax forms. We have enclosed a check for your Federal Employees' Group Life Insurance (FEGLI) claim. If you have questions or need further help, please call the OFEGLI customer service toll-free number at 1-800-633-4542. To ensure the timely receipt of year end tax information, please call the OFEGLI customer service toll-free number or write the Office of Federal Employee's Group Life insurance to report any change of address. Written notification must include the insured's name and Social Security or Claim Number. Office of FaderefJy~~ Group Life Insurance P. O. Box 2627 ~-'P No- ,IerBeycity, NJ .,~27 0017f~C1~ Clsi.t No, yf~uoa of losere! 20070100658 ~ -f VE LY STEWART O3°i PAY TO TNEORDER OF: 1 ~ O 62-35/311'' !f Paymerft Ir>cgt~ SetUeRlet1t Check ~Meerher irk K Is Subject to Federal and Loca11,-ax ~aWS. 4~fl 113842 7 e of Birth Date of peaty Interest Not Vapd Before 31-1926 10-26-2006 $ 105:01 FEB/18/2009 Amount oolfn Ilavid`~~ss i e Ad~in of the Est Of Dollars c..t: Evelyn ~~Stewart decd **'~3375+~61 THE BANK OF NEW YORK ~ g E Newark, Delaware sod Drive ~h~~G:Ch~~rn Di 1.7nrr ~ / lTff/~• .rA~ COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SHORT CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 13th day of January, Two Thousand and Nine, Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of CHARLOTTE EVELYN STEWART late of M/DDLESEX TOWNSH/P (First, Midd/e, Last) in said county, deceased, to DAVID C GUSSIE (First, Midd/e, Lastl and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 13th day of January Two Thousand and Nine. File No. PA File No. Date of Death S.S. # 2008- 00062 21- 08- 0062 10/26/2006 188-07-1735 NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL • ' DURABLE GENERAL POWER OF ATTORNEY I, Charlotte Evelyn Stewart of Mechanicsburg, Cumberland County, Pennsylvania, do hereby appoint, David C. Gussie of Mechanicsburg, Cumberland County, Pennsylvania, as my true and lawful Attorney-in-Fact with full power to transact any and all business in my name as though I myself were acting. THIc POWER includes, but is not limited to, the following: 1. To write ch~,cks, and to execute and deliver payment and withdrawal orders on any accounts that I may nave with any bank or other similar institution, and to deliver the checks of mone~~ ,paid or withdrawn to any person, group of persons, or associations; and to endorse checks or other instruments for deposit or collection; 2. To take all lawful steps to recover, collect, and receive any amounts of money now or hereafter owing or payable to me; and to compromise and execute releases or other sufficient discharges for them; 3. To withdraw and receive the income or corpus of any trust over which I may have a right of withdrawal, and to request and receive the income or corpus of any trust with respect to which the trustee thereof has the discretionary power to make distributions to or on my behalf, and to execute a receipt and release or such similar document for the property so received; 4. To sue and settle suits of any kind in my name or for my benefit; 5. To buy, sell, mortgage, hypothecate or grant security interests in any kind of tangible or intangible personal property; 6. To sign, assign, or endorse any security issued by any corporation, bank, or other organization, and to exercise any rights with respect thereto that I may have; 7. To lease, sell, release, convey, extinguish, or mortgage any interest in real property on such terms as may be deemed advisable; and to manage, repair, improve, maintain, restore, build,. or develop such property; 8. To purchase or otherwise acquire any interest in, and acquire possession of real property, and to accept all deeds and other assurances in the law for such property; 9. To execute, deliver, and acknowledge deeds, deeds of trust, covenants, indentures, agreements, mortgages, hypothecation, bills of lading, bills, bonds, notes, receipts, evidences ror debts, releases, and satisfactions of mortgages, judgment, ground rents, and other debts; 10. To enter my safe deposit boxes and to open new safe deposit boxes, and to add to, and to remove any of the contents of any such safe deposit boxes; and to close out any of the boxes; 4 1 1. To borrow money for my account of whatever terms and conditions may be deemed advisable, including the right to borrow money on any insurance policies issued on my life for any purpose and to pledge, assign, and deliver the policy or policies as security. 12. To purchase United States Treasury "flower" bonds on my behalf, and to borrow money specifically to enable the purchase of these bonds; 13. To prepare, execute, and file all tax returns required to be made by me, to pay the taxes due, to collect any refunds, to sign waivers extending the period for the assessment of such taxes of deficiencies in them, to sign consents to the immediate assessment of deficiencies and acceptance of proposed over assessments, to execute closing agreements, to engage and appoint attorneys to represent me in connection with any matters arising before any federal, state, or local taxing agency; 14. To disclaim any interest in property, to exercise my right to claim an elective share of the estate of my spouse, and to take all actions that my attorney-in-fact deems appropriate to effectuate that election; 15. To renounce any fiduciary positions to which I have been or may be appointed, including, but not limited to, personal representative, trustee, guardian, attorney-in-fact, and officer or director of a corporation; to resign such positions in which capacity I am presently serving, and to file an accounting with a Court of competent jurisdiction, or settle on a receipt and release or other informal method as my attorney-in- fact deems advisable; 16. To arrange for my entrance to, and care at, any hospital, nursing home, health center, convalescent home, retirement home, or similar institution, and to authorize, arrange for, and to consent to any and all medical and surgical procedures on my behalf and to pay all bills for my care; 17. To execute a revocable agreement of trust with such trustees as my attorney-in-fact selects and which provides that all income and principal shall be paid to me or the guardian of my estate, or applied for my benefit in such amounts as I, or my attorney-in-fact, shall request or as the trustee or trustees shall determine, and that on my death any remaining income and principal shall be paid to my personal representative, and that the trust may be revoked or amended by me or my attorney-in-fact at any time and from time to time, provided, however; that any amendment by my attorney-in-fact must be such that it could have, by law, delivered and conveyed any or all of my assets to the trustee or trustees, and to add any or all of my assets to such a trust already in existence at the time of the creation of this Power. And I do hereby ratify and confirm all that my attorney-in-fact shall lawfully do, or cause to be done, by virtue of this Power of Attorney. This Power of Attorney shall not be affected by my disability or incapacity or by uncertainty as to whether I am dead or alive, and it may be accepted and relied upon by anyone to whom it is presented until such person either (1) receives written notice of revocation by me or a guardian (or similar fiduciary) of my estate, or (2) has actual knowledge of my death. _ __ _ _ _ i _~ My attorney-in-fact shall be entitled to reasonable compensation for services performed hereunder. IN WITNESS WHEREOF, and intending to be legally bound hereby, I have signed this Power of Attorney this ~ K-f~ day of , 199 C,H ~ /~ ~ ~~rc ~ i~~ Y~ s r~~~,~~ WITNESS: ~~ ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CLLL4/ SS. On this 3•cd~ day of / 199 before me, the undersigned, personally app ared, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein ontained. IN WITNESS WHEREOF, I have hereunto set my hand and Notarial Seal. ~~ ~~~ ~'f. ~~ j NOTARIAL SEAL SUE A. CLAIR, Notary Pwblic Lower Allen Twp., Cumberland Co. PA My Commission Expires Dec. 28, 1998 .~ Durable Power of Attorney for Health Care (Pennsylvania Statutes Annotated title 20, §§ 5601 to 5607) Print your full name am of sound mind and I voluntarily make this Durable Power of Attorney for Health Caze. There aze two parts to this document: Part 1 sets forth my health-caze instructions; Part 2 appoints a person to make health-care decisions for me on matters not covered in my instructions. This document shall take effect upon my incapacity. PART 1-Health-Care Instructions (2) I am one of Jehovah's Witnesses. On the basis of my firmly held religious convictions, see Acts 15:28, 29, and on the basis of my desire to avoid the numerous hazazds and complications of blood, I absolutely, unequivocally and reso- lutely refuse homologous blood (another person's blood) and stored sutologous blood (my own stored blood) under any and all circumstances, no matter what my medical condition. This means no whole blood, no red cells, no white cells, no platelets, and no blood plasma no matter what the consequences. Even if health-care providers (doctors, nurses, etc.) believe that only blood transfusion therapy will preserve my life or health, I do not want it. Family, rela- tives or friends may disagree with my religious beliefs and with my wishes as expressed herein. However, their disa- greement is legally and ethically irrelevant because it is my subjective choice that controls. Any such disagreement should in no way be construed as creating ambiguity or doubt about the strength or substance of my wishes. Also, because many health-care providers view Jehovah's Witnesses' refusal of blood with disapproval and even hostility, I am concerned that someone may claim that I orally consented to a blood transfusion. Thus, I hereby state that it is my conscious decision that my absolute refusal of blood transfusion shall not be revocable by me orally. If anyone claims that I have orally consented to a blood transfusion, I demand that such claim be ignored unless confuined in writing signed by me and subscribed by at least two disinterested witnesses. (3) With respect to minor blood fractions* or products containing minor blood fractions, according to my conscience I ~- initial one of the three choices below] ~C ~ r(a) NNE. (c) SOME. That is, I ACCEPT: [initial choice(s) below) Products that may have been processed with or contain small amounts of albumin (e.g., streptokinase, and some recombinant products [such as etythropoietin (EPO) and synthesized clotting factors], and some radionuclide scan preparations may contain albumin). Immunoglobulins (e.g., Rh immune globulin, gammaglobulin, horse serum, snake bite antivenins). Clotting factors (e.g., fibrinogen, Factors VII, VIII, IX, XII). Other: (4) I accept and request alternative nonblood medical management to build up or conserve my own blood, to avoid or minimize blood loss, to replace lost circulatory volume, or to stop bleeding. For example, volume expanders such as dextran, saline or Ringer's solution, or hetastazch would be acceptable to me. (5) With respect to non-stored sutologous blood* (my own non-stored blood), according to my conscience I ACCEPT: 'ce(s) below] s (a) D ALYSIS oR HEART-LUNG EQUIPMENT (diversion of my blood within an extracorporeal circuit that does not urvolve storage or thoee than brief interruption of blood flow and that is constantly linked to my circulatory system, provided any equipment used is not primed with stored blood). ~: ~ y s (b) EMOD[Lt1TION (dilution of my blood within an extracorporeal circuit that does not involve storage or more than brief interruption of blood flow and that is constantly linked to my cvculatory system, provided any equipment used is not primed with stored blood). (c) INTRAOPERAT[VE OR POSTOPERATIVE BLOOD SALVAGE (contemporaneous recovery and reinfusion of blood lost during or after surgery that does not revolve storage or more than brief intemtption of blood flow, pro- vided any equipment used is not primed with stored blood). (d) NONE. your Page 1 of 4 ~-ZI-~i~ - ., .. (6) With respect to providing, withholding, or withdrawing life-sustaining treatment at the end of life, and consistent with ~,,._.E ania Statutes Annotated title 20, § 5404, my declaration, which in no way alters my absolute refusal of blood as vetted ve, is: [initial one of the three choices below] )( ~_ S (a) N To PROLONG LIFE.' That is, if to a reasonable degree of medical certainty my condition is hopeless (for ample, if to a reasonable degree of medical certainty I have an incurable and irreversible condition that will result in my death within a relatively short time, or if I am unconscious and to a reasonable degree of medical certainty will not regain consciousness, or if I have brain damage or a brain disease that makes me unable to recognize people or communicate and to a reasonable degree of medical certainty my condition will not improve), I do not want my life to be prolonged. Thus, in such situations, I do not want mechanical respiration (ventilation), cardiopulmonary resuscitation (CPR), tube feeding (artificial nutrition or hydra- tion), etc. However, I do want palliative care-treatment for comfort. (b) TO PROLONG LIFE. That is, I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards, although I realize this means that I might be kept alive on machines for years in a hopeless condition. (c) OTHER. [If you do not completely agree with either (a) or (b) above, you can initial here and write your own end-of--life instructions in the space provided.-NOTE: Unless your agent knows your wishes about artificial nutrition and hydration, your agent may not be able to make decisions about these matters.) (7) Other health-care instructio (e.g., you~i~ es regarding organ nation, current medication, allergies, other medical problems, etc.): l11 ~ e ''CC (8) I am primarily concerned that my refusal of blood and choice of alternative nonblood management be respected regardless of my medical condition. My rights under the federal and state constitutions and state common law require health-care providers to respect and comply with my treatment decisions. My rights are not dependent on, and do not vary with, my medical condition. Thus, my decision to refuse blood and choose nonblood management must be re- spected even if my life or health is deemed to be threatened by my refusal. Stamford Hosp. v. Vega, 674 A.2d 821 (Conn. 1996) (Witness patient's refusal of blood protected by state common law right of bodily self-determination); In re Dubreuil, 629 So. 2d 819 (Fla. 1993) (Witness patient's refusal of blood protected by state constitutional rights of personal privacy and religious freedom); Norwood Hosp. v. Munoz, 564 N.E.2d 1017 (Mass. 1991) (Witness patient's refusal of blood protected by state common law right of bodily self-determination and federal constitutional right of personal privacy); Fosmire v. Nicoleau, 551 N.E.2d 77 (N.Y. 1990) (Witness patient's refusal of blood protected by state common law right of bodily self-determination); In re E.G., 549 N.E.2d 322 (Ill. 1989) (Witness patient's refusal of blood protected by state common law right of bodily self-determination); Public Health Trust v. Woes, 541 So. 2d 96 (Fla. 1989) (Witness patient's refusal of blood protected by state consritutional rights of personal privacy and religious freedom); In re Milton, 505 N.E.2d 255 (Ohio 1987) (non-Witness patient's religion-based refusal of treatment pro- tected by lst Amendment guarantee of free exercise of religion); In re Brown, 478 So. 2d 1033 (Miss. 1985) (Witness patient's refusal of blood protected by state constitutional rights of personal privacy and religious freedom); In re Os- borne, 294 A.2d 372 (D.C. 1972) (Witness patient's refusal of blood protected by 1st Amendment guarantee of free exercise of religion); In re Estate of Brooks, 205 N.E.2d 435 (Ill. 1965) (Witness patient's refusal of blood protected by 1st Amendment guarantee of free exercise of religion). ' [This footnote applies only to pregnant women.] If I am pregnant and there is a reasonable chance my fetus could survive, I want my life to be prolonged for the sake of my fetus, notwithstanding my instructions in Paragraph (6)(a). However, in no way does this change my wishes about nonblood treatment for both .myself and my fetus. After any efforts to save my fetus, my instructions in Paragraph (6)(a) shall again control. Page 2 of 4 .'.~ ~ ,~ The United States Supreme Court has said that "[i]t is settled now ... that the Constitution places limits on a State's right to interfere with a person's most basic decisions about ... bodily integrity." Planned Parenthood v. Casey, 505 U.S. 833, 849 (1992). In Cruzan v. Missouri Department of Health, 497 U.S. 261 (1990), the Supreme Court stated: "It cannot be disputed that the Due Process Clause [of the Fourteenth Amendment to the United States Constitution] pro- tects aninterest in life as well as an interest in refusing life-sustaining medical treatment." Id at 281. The Court also said: "The principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medi- cal treatment may be inferred from our prior decisions." Id. at 278. In addition, in Washington v. Harper, 494 U.S. 210 (1990), the Supreme Court said that prison inmates suffering from mental disorders possess "a significant liberty inter- est in avoiding the unwanted administration of antipsychotic drugs under the Due Process Clause of the Fourteenth Amendment." Id at 221-22. The Court also observed that "[t]he forcible injection of medication into a nonconsenting person's body represents a substantial interference with that person's liberty." Id at 229. There is no indication in these Supreme Court cases that a person must be in a terminal, irreversible, incurable or untreatable condition, or in a permanently unconscious or vegetative state in order to exercise his fundamental Four- teenth Amendment right to refuse treatment or otherwise control what is done to his body. Indeed, Nancy Cruzan her- selfwas not terminally ill. See 497 U.S. at 266, n. l . Moreover, implicit throughout the majority opinion in Cruzan and expressly stated in Justice O'Connor's concurrence and all the dissents (except Justice Scalia's) is the acceptance of advance written directives as cleaz and convincing evidence of a formerly competent patient's wishes. Therefore, be- cause Ihave prepazed this advance directive while competent, if I become incompetent, my wishes as expressed herein must be respected as if I were competent. (9) [This paragraph applies only to pregnant women.) In Planned Parenthood v. Casey, SOS U.S. 833, 860 (1992), the Su- preme Court confirmed that "viability mazks the eazliest point at which the State's interest in fetal life is constitutionally adequate to justify a legislative ban on therapeutic abortions." Thus, since I have the right to abort my pregnancy before viability I necessarily have the lesser right to refuse blood transfusions before viability. In addition, even if my fetus is viable, the Supreme Court has said that mothers cannot be exposed to increased medical risks for the sake of their fe- tuses and that the state's interest in the potential life of the fetus is insufficient to override the mother's interest in pre- serving her own health. Thornburgh v. American College of Obstetricians dr Gynecologists, 476 U.S. 747, 768-71 (1986); see Planned Parenthood v. Casey, 505 U.S. 833, 846 (1992). Also, in the cases of In re A.C., 573 A.2d 1235 (D.C. 1990), and In re Doe, 632 N.E.2d 326 (III. App. Ct.), cert. denied, 114 S. Ct. 1198 (1994), refusals of treatment by women with viable fetuses were upheld. Although both of these cases involved Caesazean sections, as a matter of principle and logic they show that it is the pregnant woman who should decide what is to be done to herself and her fetus. Therefore, I demand that my refusal of blood and choice of alternative nonblood management be followed and that my doctors manage my caze and the caze of my fetus without transfused blood. (10) In sum, based on federal and state constitutional law and state common law, I demand that the instructions set forth in this document be followed regardless of my medical condition. Any attempt to administer blood to me contrary to my instructions will be a violation of my Fourteenth Amendment liberty interest in bodily self-determination, my First Amendment right of religious free exercise, my state constitutional rights of personal liberty or privacy and religious freedom, and my state common law rights of bodily self-determination and personal autonomy. PART 2-Appointment of Health-Care Agent (11) I hereby appoint the following person as my health-caze agent: [Notice: You may choose any adult to be your agent, but it is recommended that you not choose your doctor, any of your doctor's employees, or any employee of a hospital or nursing home where you might be a patient, unless the individual is related to you by blood, marriage, or adoption.] ~ ., Agent's full name: (~ S / ~. Agent's address: ~ f _ Work Telephone: ( ) ~ /~-~ Q Home Tele hone: 1 tP b ~'~l 3 Other: P (~)~// //_ c/~ ( ) y (12) If the agent appointed above is unavailable, unable, or unwilling to serve or continue to serve, then I appoint the following alternate agent to serve with the same powers: [See "Notice" in Pazagraph 11 above.] Alternate agent's full name Alternate agent's address: Work Telephone: Home Telephone: ( ) Other: ( ) (13) To the extent this document sets forth my health-care instructions, there is no need or reason to look to my agent for a decision. However, I grant my agent full power and authority to ensure that the wishes expressed in this document are followed by health-caze providers. Further, I grant my agent full power and authority to make health-caze decisions for me on matters not covered by this document. My agent's authority is effective as long as I am incapable of making my own health-caze decisions. (14) In harmony with the limitations in the preceding paragraph, my agent's authority shall include but not be limited to the following: (a) To consent to, refuse, or withdraw consent to any or all types of medical care treatment, surgical procedures, diag- nostic procedures, medication, and the use of other mechanical or other procedures related to health care. This authorization includes the power to consent to pain-relieving medication for relief of severe and intractable pain. (b) To request, review, and receive any information, oral or written, regazding my physical or mental health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this information. (c) To employ or discharge my health-caze providers; to authorize my admission to or discharge from any hospital, nursing home, mental health or other medical care facility; and to take any lawful actions that may be necessary to carry out my wishes, including the granting of releases from liability to health-care providers. (15) A copy of this document shall be as valid as the original. I ask that a copy of this document be made part of my perma- nent medical record. I have provided copies of this document to my health-caze agent and alternate agent. It is my intention that this document be honored in any jurisdiction in which it is presented and that it be construed liberally to give my agent the fullest discretion in making health-care decisions in my behalf consistent with my instructions. (16) If my health-care providers cannot respect my wishes as expressed in this document or as otherwise known to my agent and a transfer of care is necessary to effectuate my wishes, I direct my health-caze providers to cooperate with and assist my agent in promptly transferring ttte. to_ another, health-caze provider that will respect my wishes. In such circum- stances, Idirect my health-care providers to transfer promptly all my medical records, including a copy of this docu- ment, to the other health-care provider. (17) This document revokes any prior health-caze power of attorney or health-care proxy executed by me. (18) The provisions of this entire document aze separable, so that the invalidity of one or more provisions shall not affect any others. (19) I understand the full import of this document and I am emotionally and mentally competent to execute it. J p. o~ p p (20) SIGNED: C _ 1 = ~ l.c. ~ 'f i`~ I 't ~ ~' ~ w A ~ 7 6 / / 6 our signature Date Address (21) STATEMENT BY WITNESSES: I declare that the person who signed this document (the principal) or the person who signed on behalf of and at the direction of the principal knowingly and voluntarily signed this writing by signature or mazk in my presence. Also, I am not the person appointed as agent or alternate agent by this document. Signature of witness 1 Print name Address ._ ` LJ ~~ Signature of witness 2 ~~ ~/Q/tC~, ,~l.~J y-19-9~ ~yrS 1/~avd Print name 37 s CI Avervt.tr+v~.~- D yl ve, Address ~ ~ ~ ~ S ~ ~ ~r4 (?~r7 13 Page 4 of 4 v COMMONWEALTII OF PhNNSYLVAATIA) SS: COUNTY OF CIII~ERLAND ) On this, the 29th day of September, 1998, before me a notary public, the undersigned officer,. personally appeared C. Evelyn Stewart, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged tht she executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand as official seal. VG2/~= ~i ~ - s ~.~~ Q Patricia A. Meck Notary Public Notarial Seal f'ataricas A. Meck. Notary Public _ f~Addiasex TWp., Cumberland County } - ~`' ~ Corwmisston Expires Nov. 8, 2001 ember, Pennsylvania Association of Notaries