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HomeMy WebLinkAbout895142 DURABLE pOwER OF ATTORNEy FOR HEALTH CARE · DURABLE GENERAL POWER OF ATTORNEY ARTICLE I. APPOINTMENT OF ATTORNEY-I~-FACT RECEIVED LINOOLN COUNTy CLERK 03NOV-7 PH 3:1~ JEANNE VCAGNER Y,~M'MERER, I, Jacob S. Kellersberger (hereinafter sometimes referred to as "Principal"), appoint Craig M. Kellersberger, as my agent and attorney-in-fact, without substitution, with lawful authority to execute a directive on my behalf under Section 3-5-101 et. seq, of the Wyoming Statutes governing the care and treatment to be administered to or withheld from me at any time after I incur an injury, disease, or illness which renders me unable to give current directions to attending physicians and other providers of medical services, and I appoint Craig M. Kellersberger as my Attorney-in-Fact (hereinafter referred to as "Attorney"). If the person appointed as Attorney should at any time for any reason be unable to or unwilling to act or to continue to act as Attorney, then I appoint as Attorney the person(s) hereinafter named, as "Successor Attorney-in-Fact." Effective Date This Durable Power of Attorney shall become effective upon the incapacity of the Principal. Severabili~ In the event that any provision herein is invalid, the remaining provisions shall nonetheless be in full force and effect. ARTICLE H. DURABLE POWER OF ATTORNEY FOR HEALTH CARE I wish to live and enjoy life as long as possible, but I do not wish to reCeive futile medical treatment, which I define as treatment that will provide no benefit to me and will only postpone my inevitable death or prolong my irreversible coma. I desire that my wishes be carried out through the authority given to my Attorney-in-Fact (as designated herein) by this document despite any contrary feelings, beliefs or opinions of other members of my family, of relatives or of friends. Power To Exercise Health Care Decisions My Attorney is authorized to, and may make health care decisions for me, before or after my death, to the same extent as I would make health care decisions for myselfifI had the capacity to do so, including but not limited to, consenting to health care, or consenting to the withholding or Page -1- withdrawal of health care necessary to keep me alive. Duration This Durable Power of Attorney for Health Care shall terminate at such time as required by law, unless at such expiration date I lack the capacity to make health care decisions for myself, in which case this Durable Power of Attorney for Health Care shall continue in effect until the time when I regain the capacity to make health care decisions for myself. Medical Records My AttOrney shall have the same right as I have to receive information regarding my proposed health care, to receive and review medical records, and to consent to the disclosure of medical records. RefUsal or Maximization of Medical Treatment In exercising the authority given to my Attorney herein, my Attorney should try to discuss with me the specifics of any proposed derision regarding my medical care and treatment ifI am able to communicate in any manner, even by blinking my eyes. My Attorney is further instructed that if I am unable to give an informed consent to medical treatment, my Attorney shall give or withhold such consent for me based upon any treatment choices that I have expressed while competent, whether under this instrument or otherwise. If my Attorney cannot determine the treatment choice I would want made under the cirCUmstances, then my Attorney should make such choice for me based upon what my Attorney believes to be in my best interests. Accordingly, if: My treating physician who is familiar with my condition has diagnosed and noted in my medical records that my condition is incurable, terminal and expected to result in my death within twelve (12) months regardless of what medical treatment I may receive, and he has determined that I am unable to give informed consent to medical treatment; or My treating physician who is familiar with my condition ha diagnosed and noted in my medical records that I have been in a coma for at least fit~een (15) days and that the coma is, under their opinion, irreversible, meaning that there is no reasonable possibility of my ever regaining consciousness, then my Attorney is authorized as follows: (1) To sign on my behalf any documents necessary to 'carry out the authorizations described below, including waivers or releases of liability required by any health care provider, (2) To give or withhold consent to any medical care or treatment, to revoke or change any consent previously given or implied by law for any medical care or treatment, and to arrange for my placement in or removal from any hospital, convalescent home, Page -2- hospice or other medical facility, and (3) To require that medical treatment wtfich will only prolong my inevitable death or irreversible coma (including bY way of example only, treatment such as cardiopulmonary resuscitation, surgery, dialysis, the use of antibiotics, or transplants) not be instituted or, if previously instituted, to require that it be discontinued. (4) To require that procedures used to provide me with nourishment and hYdration (including, for example only, intravenous feedings, endotracheal or nasogastic tube use) not be instituted or, if previously instituted, to require that they be discontinued, but only if the two (2) physicians described, above also determine that I will not experience excessive pain as a result of the withdrawal of nourishment or hydration. ARTICLE m. DURABLE GENERAL POWER OF ATTORNEY Incapacity The Principal shall be deemed to be incapacitated if at any time a licensed physician certifies in writing that the Principal has become physically or mentally incapacitated and is unable to manage his affairs in his best interest, whether or not a Court of competent jurisdiction has declared the Principal incompetent, mentally ill or in need of a conservator. Powers Exercisable by Attorney The Attorney is given and granted hereby full power and authority to do for Principal and in Principal's name, place and stead, and for Principal's use and benefit, all and every act and thing whatsoever, and to undertake anY and ,all transactions, acts and proceedings in the Principal's name, place and stead for the purpose of transacting any and all business of every kind, nature and description whatsoever in connection with Principal's business and personal affairs relative to any property interest, real or personal, of Principal's .now owned or hereafter acquired, as fully and to all intents and purposes as Principal might or could do if personally acting. Attorney is specifically empowered and directed to transfer and convey to the Trustee or Trustees then acting under any Revocable Trust (Grantor's Trust) under which Principal is a Settlor (Grantor/Trust0r) and a beneficiary, any or all assets now or at any time or times hereinafter standing in Principal's name (or representing Principal's interest in assets owned jointly, commonly and/or otherwise with any other person or persons). Attorney is given and granted hereby full Power and aUthority to make, verify and file federal, state and/or local income, gift and/or other tax returns of all kinds, claims for refund, requests for extension of time, petitions to the tax court or other courts regarding tax matters and/or any and all other tax related documents, including receipts, offers, waivers, consents, powers of attorney and closing agreements, of all kinds without limit, and generally to act on behalf Page -3~ of the Principal in all tax matters of all kinds and for all periods before all officers of the Internal Revenue Service and/or any other taxing authority, including receipt of confidential information, and to cause the Principal to be represented in any and all such proceedings; Attorney is given and granted hereby full power and authority to sign and deliver qualified disclaimers as to any girl or inheritance as provided for under the Internal Revenue Code of 1954, as amended from time to time; Attorney is given and granted hereby full power and authority to make gifts to Principal's spouse, if any, child or children and other descendants or ascendants, if any, and/or to charitable, scientific, religious or educational institutions, and to consent to split gifts made by Principal's spouse to third persons, keeping in mind Principal's best interests and the best interests of Principal's family; Attorney is given and granted hereby full power and authority to exercise any special or general power of appointment held by Principal, keeping in mind Principal's best interests and the best interests of Principal's family; Attorney is given and granted hereby full power and authority to designate the beneficiary under any policy of life insurance and under any employee benefit plan, keeping in mind Principal's best interests and the best interests of Principal's family. Attorney is given and granted hereby full power and authority to sign any deeds or transfer any property Attorney deems necessary, including real and personal property. The Principal hereby ratifies and confirms all that said Attorney shall do or cause to be done by virtue hereof, and all documents of any kind (without limitation) executed and/or delivered by AttorneY shall bind the Principal and the Principal's heirs, distributees, legal representatives, 'succesSors and assigns. Powers NOT Exercisable by Attorney Attorney shall not have the power to undertake the following acts on behalf of the Principal: Vote a proxy given by ~ person to another person with respect to the exercise of voting rights; Make a Will or Codicil to a Will for Principal or revoke Principal's Will or Codicil; or change, modify or direct the revocable Living Trust of the Principal; Exercise any powers under any irrevocable trust of which Attorney is the creator and Principal is the Trustee; Page -4- 234- 4. Exercise any power in any way to discharge any legal obligation that Attorney may have. Limitation of Liability For the purpose of inducing any bank, broker, custodian, insurer, lender, transfer agent and/or other party to act in accordance with the powers granted in this Durable Power of Attorney, the Principal hereby represents, warrants and agrees that, if this Power of Attorney is terminated for any reason whatsoever, the Principal and the Principal's heirs, distributees, legal representatives, successors and assigns will save such party or parties harmless from any loss suffered or liability incurred by such party or parties in acting in accordance with this Power of Attorney prior to such party's or parties' receipt of written notice of any such termination. ARTICLE IV. NOMINATION OF CONSERVATOR If a conservator is to be appointed for me, I nominate the person(s) named herein as my Attorney-in-Fact to serve as conservator of my person. ARTICLE V. REVOCATION OF PRIOR POWERS OF ATTORNEY This POwer of Attorney revokes any prior Durable Power of Attorney, both GENERAL and FOR HEALTH CARE, executed previously by Principal. ARTICLE VI. SIGNATURE BY ATTORNEY When signing on behalf of Principal under this Power of Attorney, Attorney shall sign as follows: "Jacob S. Kellersberger by Craig M. Kellersberger, his Attorney-in-Fact." ARTICLE VII. NOMINATION OF SUCCESSOR I nominate and appoint as Successor Attorneys to serve by virtue of the authority herein granted the following: First Successor: : Kent M. Kellersberger Second Successor: Karen Timothy The condition under which any person named above as successor attorney may exercise any Page -5- 235 powers set forth herein is that any person who is at the time authorized hereunder to serve as my Attorney shall be unable or unwilling to serve or to continue to serve as Attorney, then in the order specified above, the first person named above as successor Attorney who is willing and able to serve as such Attorney shall be fully authorized to serve hereunder and shall have all of the powers granted ori~'nally to my Attorney and the term "Attorney" shall refer to such person so serving. Any successor Attorney may eXeCute an affidavit that my Attorney is unwilling or unable to serve or continue to serve and such affidavit shall be conclusiv~ evidence, insofar as third parties are concerned, of the facts set forth therein, and in such event any person acting in reliance upon such affidavit shall incur no liability to my estate because of such reliance. Dated: ARTICLE VIIL DECLARATION OF PRINCIPAL The Principal hereby declares under oath that the following is correct: The Principal has been advised, in regard to this Durable General Power of Attorney, and Durable Power of Attorney for Health Care and its consequences; Principal understands that the Durable General Power of Attorney gives to the Attorney nominated herein, broad powers to dispose, sell, convey and encumber Principal's real and personal property, which powers arise on Principal's disability or incapacity; and Principal understands that theSe powers for the General Durable Power of Attorney will exist for an indefinite period of time after Principal's disability or incapacity unless their duration has been limited in this document. Page -6- 236 "l declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the princiPal, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as attorney in fact by this document, and that I am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility." ' "~ ~iin-e-~s ~)at'e ' I further declare under penalty of perjury under the laws of Wyoming that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or our names to this instrument, being first duly swodn, and do hereby~leclare to the undersigned authority that the Principal signs and executes this instrument in our presence as his Durable Power of Attorney for Health Care and as a General Power of Attorney, and that he signs it willingly, and thai he executes it as his free and voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing of the Principal, hereby signs this instrument as witnesses to the Principal's signing, and that to the best of the knowledge of each witness, the Principal is eighteen years of age or qlder, of sound mind, and under no constraint ar undue influence. ~'tness Wit~ess . ', ~ Address ~5 ' AddreSs Page -7- ,.37 STATE OF ~ ) COUN YO ) SU~_ SgRIBED AND SWORN to and acknowledged before me, a Notary Public, On this/JTday of ~ , 2002, by Jacob S. Kellersberger, the Principal, and by ,"fl_~.ff~_ Uffa~.or~,., and~. ~. ~f~.,~,~o~ [,~.,~.',d~ . , the witnesses, personally known to me or proved to be the persbns whose signa~tures are subscribed to the within instrument and ac_knowledged the/y exe,~uted the same. Address:7--_-~{Od- ~q'[/~d. ~ (~,; ~.'~ My commission expires:. ~/on~.~/o~ (' Page -8-