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The document is an Advance Health Care Directive for Marta Romero Rodriguez, designating Mauricio Torres Romero as the primary agent for health care decisions, with alternate agents named. It outlines the agent's authority, including end-of-life decisions and pain relief preferences, and specifies that the agent can dispose of remains by cremation. The directive also includes provisions for psychiatric treatment and states that no organ donation or primary physician information is included.

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2 views3 pages

Screenshot 2024-01-31 at 11.04.55 AM

The document is an Advance Health Care Directive for Marta Romero Rodriguez, designating Mauricio Torres Romero as the primary agent for health care decisions, with alternate agents named. It outlines the agent's authority, including end-of-life decisions and pain relief preferences, and specifies that the agent can dispose of remains by cremation. The directive also includes provisions for psychiatric treatment and states that no organ donation or primary physician information is included.

Uploaded by

hbwctnkzw2
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

California Advance Health Care Directive

for
Marta Romero Rodriguez
(California Probate Code Section 4701)

*****************
PART 1
POWER OF ATTORNEY FOR HEALTH CARE

(1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make


health care decisions for me:

Mauricio Torres Romero


(name of individual you choose as agent)

3059 Capp St, Oakland, California 94602


(address of agent)

(510) 418-6428
(phone) (alt. phone)

Rosa E Allen
(name of individual you choose as first alternate agent)

5000 Cloudcrest PL., Roseville, California 95747


(address of agent)

(925) 566-8668
(phone) (alt. phone)

Martha Catalina Arreola Romero


(name of individual you choose as second alternate agent)

1115 Virginia Ln #1, Concord, California 94520


(address of agent)

(925) 565-4656
(phone) (alt. phone)

If more than one agent is appointed, each agent can act


independently.
(1.2) AGENT’S AUTHORITY: My agent is authorized to make all health care decisions for
me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and
all other forms of health care to keep me alive.
(1.3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority
becomes effective immediately.
(1.4) AGENT’S OBLIGATION: My agent shall make health care decisions for me in
accordance with this power of attorney for health care, any instructions I give in Part 2 of this
form, and my other wishes to the extent known to my agent. To the extent my wishes are
unknown, my agent shall make health care decisions for me in accordance with what my agent
determines to be in my best interest. In determining my best interest, my agent shall consider my
personal values to the extent known to my agent.
(1.5) AGENT’S POSTDEATH AUTHORITY: My agent is authorized to dispose of my remains
by cremation. It is my wish that my ashes be returned to Mexico and buried in my family
cemetery.
(Add additional sheets if needed.)
(1.6) NOMINATION OF CONSERVATOR: If a conservator of my person needs to be
appointed for me by a court, I nominate the agent designated in this form. If that agent is not
willing, able, or reasonably available to act as conservator, I nominate the alternate agents whom
I have named, in the order designated.

PART 2
INSTRUCTIONS FOR HEALTH CARE
(2.1) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in
my care provide, withhold, or withdraw treatment in accordance with the following instructions:
I do not want my life to be prolonged 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 not regain consciousness, or (3) the
likely risks and burdens of treatment would outweigh the expected benefits.
(2.2) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for
alleviation of pain or discomfort be provided at all times, even if it hastens my death, unless
medical experts conclusively determine that I am not in the terminal phase of my life. In the
event that medical professionals ascertain that I have reached the end stage of my life, I wish to
be provided with compassionate palliative care to manage pain and symptoms, prioritizing
comfort and dignity over aggressive medical interventions.

(2.3) WISHES FOR PHYSICAL AND MENTAL HEALTH CARE:


a. Consent to psychiatric treatment
Upon the execution of a certificate by two independent psychiatrists who have examined me and
in whose opinions I am in immediate need of hospitalization because of mental disorders,
alcoholism, or drug abuse, my Healthcare Agent may arrange for my voluntary admission to an
appropriate hospital or institution for treatment of the diagnosed problem or disorder; to arrange
for private psychiatric and psychological treatment for me; and to revoke, modify, withdraw, or
change consent to the hospitalization, institutionalization, or private treatment that I or my
Healthcare Agent may have previously given. The consent of my Healthcare Agent to my
hospitalization for psychiatric help, alcoholism, or drug abuse has the same legal effect, subject
to applicable local law, as a voluntary admission made by me.

PART 3
DONATION OF ORGANS, TISSUES, AND PARTS AT DEATH
(OPTIONAL)
I choose not to include provisions for donation of my organs, tissues, and parts.

PART 4
PRIMARY PHYSICIAN
(OPTIONAL)
I choose not to include primary physician information.
*****************
PART 5

(5.1) EFFECT OF COPY: A copy of this form has the same effect as the original.
(5.2) SIGNATURE: Sign and date the form here:

(date) (sign your name)

Marta Romero Rodriguez


(print your name)
3059 Capp St
(street address)

Oakland, California 94602


(city, state zip)

(5.3) 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 personally 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 individual 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 health 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 residential care facility for the elderly, nor an employee of an operator
of a residential care facility for the elderly.

First witness Second witness

(print name) (print name)

(address) (address)

(city, state zip) (city, state zip)

(signature of witness) (signature of witness)

(date) (date)
(5.4) ADDITIONAL 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 related 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 their death
under a will now existing or by operation of law.

(signature of witness) (signature of witness)

California Advance Health Care Directive for Marta Romero Rodriguez


Page 6 of 17

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