HEALTH CARE POWER OF ATTORNEY

INFORMATION ABOUT THIS DOCUMENT

THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD
KNOW THESE IMPORTANT FACTS:

1. THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR AGENT THE POWER TO MAKE
HEALTH CARE DECISIONS FOR YOU IF YOU CANNOT MAKE THE DECISION FOR
YOURSELF. THIS POWER INCLUDES THE POWER TO MAKE DECISIONS ABOUT
LIFE–SUSTAINING TREATMENT. UNLESS YOU STATE OTHERWISE, YOUR AGENT WILL
HAVE THE SAME AUTHORITY TO MAKE DECISIONS ABOUT YOUR HEALTH CARE AS YOU
WOULD HAVE.

2. THIS POWER IS SUBJECT TO ANY LIMITATIONS OR STATEMENTS OF YOUR DESIRES

THAT YOU INCLUDE IN THIS DOCUMENT. YOU MAY STATE IN THIS DOCUMENT ANY
TREATMENT YOU DO NOT DESIRE OR TREATMENT YOU WANT TO BE SURE YOU
RECEIVE. YOUR AGENT WILL BE OBLIGATED TO FOLLOW YOUR INSTRUCTIONS WHEN
MAKING DECISIONS ON YOUR BEHALF. YOU MAY ATTACH ADDITIONAL PAGES IF YOU
NEED MORE SPACE TO COMPLETE THE STATEMENT.

3. AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE HEALTH
CARE DECISIONS FOR YOURSELF IF YOU ARE MENTALLY COMPETENT TO DO SO. AFTER
YOU HAVE SIGNED THIS DOCUMENT, NO TREATMENT MAY BE GIVEN TO YOU OR
STOPPED OVER YOUR OBJECTION IF YOU ARE MENTALLY COMPETENT TO MAKE THAT
DECISION.

4. YOU HAVE THE RIGHT TO REVOKE THIS DOCUMENT, AND TERMINATE YOUR AGENT'S
AUTHORITY, BY INFORMING EITHER YOUR AGENT OR YOUR HEALTH CARE PROVIDER
ORALLY OR IN WRITING.

5. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU

SHOULD ASK A SOCIAL WORKER, LAWYER, OR OTHER PERSON TO EXPLAIN IT TO YOU.

6. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS TWO PERSONS SIGN AS
WITNESSES. EACH OF THESE PERSONS MUST EITHER WITNESS YOUR SIGNING OF THE
POWER OF ATTORNEY OR WITNESS YOUR ACKNOWLEDGMENT THAT THE SIGNATURE

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 ON THE POWER OF ATTORNEY IS YOURS.

7. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:

A. YOUR SPOUSE; YOUR CHILDREN, GRANDCHILDREN, AND OTHER LINEAL

DESCENDANTS; YOUR PARENTS, GRANDPARENTS, AND OTHER LINEAL
ANCESTORS; YOUR SIBLINGS AND THEIR LINEAL DESCENDANTS; OR A SPOUSE OF
ANY OF THESE PERSONS.
B. A PERSON WHO IS DIRECTLY FINANCIALLY RESPONSIBLE FOR YOUR MEDICAL
CARE.
C. A PERSON WHO IS NAMED IN YOUR WILL, OR, IF YOU HAVE NO WILL, WHO
WOULD INHERIT YOUR PROPERTY BY INTESTATE SUCCESSION
D. A BENEFICIARY OF A LIFE INSURANCE POLICY ON YOUR LIFE.
E. THE PERSONS NAMED IN THE HEALTH CARE POWER OF ATTORNEY AS YOUR
AGENT OR SUCCESSOR AGENT.
F. YOUR PHYSICIAN OR AN EMPLOYEE OF YOUR PHYSICIAN.
G. ANY PERSON WHO WOULD HAVE A CLAIM AGAINST ANY PORTION OF YOUR
ESTATE (PERSONS TO WHOM YOU OWE MONEY).

IF YOU ARE A PATIENT IN A HEALTH FACILITY, NO MORE THAN ONE WITNESS MAY BE
AN EMPLOYEE OF THAT FACILITY.

8. YOUR AGENT MUST BE A PERSON WHO IS 18 YEARS OLD OR OLDER AND OF SOUND
MIND. IT MAY NOT BE YOUR DOCTOR OR ANY OTHER HEALTH CARE PROVIDER THAT IS
NOW PROVIDING YOU WITH TREATMENT; OR AN EMPLOYEE OF YOUR DOCTOR OR
PROVIDER; OR A SPOUSE OF THE DOCTOR, PROVIDER, OR EMPLOYEE; UNLESS THE
PERSON IS A RELATIVE OF YOURS.

9. YOU SHOULD INFORM THE PERSON THAT YOU WANT HIM OR HER TO BE YOUR HEALTH
CARE AGENT. YOU SHOULD DISCUSS THIS DOCUMENT WITH YOUR AGENT AND YOUR
PHYSICIAN AND GIVE EACH A SIGNED COPY. IF YOU ARE IN A HEALTH CARE FACILITY
OR A NURSING CARE FACILITY, A COPY OF THIS DOCUMENT SHOULD BE INCLUDED IN
YOUR MEDICAL RECORD.

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 HEALTH CARE POWER OF ATTORNEY

DESIGNATION OF HEALTH CARE AGENT

I, Charles Henry Thomas (Principal), hereby appoint my Daughter, Tonya Marie Virgilio, of 817
Shirley Street, Calhoun Falls, in the State of South Carolina 29628, as my agent to make health care
decisions for me as authorized in this document. Tonya Marie Virgilio can be contacted at (864) 824-
3834.

EFFECTIVE DATE AND DURABILITY

By this document I intend to create a durable power of attorney effective upon, and only during, any
period of mental incompetence.

AGENT'S POWERS
In accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d
("HIPAA"), I authorize my health care agent to review and receive any information regarding my
physical or mental health, including medical and hospital records. I grant to my agent full authority to
make decisions for me regarding my health care. In exercising this authority, my agent shall follow my
desires as stated in this document or otherwise expressed by me or known to my agent. In making any
decision, my agent shall attempt to discuss the proposed decision with me to determine my desires if I
am able to communicate in any way. If my agent cannot determine the choice I would want made, then
my agent shall make a choice for me based upon what my agent believes to be in my best interests. My
agent's authority to interpret my desires is intended to be as broad as possible, except for any limitations
I may state below.

Accordingly, unless specifically limited below, my agent is authorized as follows:

A. To consent, refuse, or withdraw consent to any and all types of medical care, treatment, surgical
procedures, diagnostic procedures, medication, and the use of mechanical or other procedures
that affect any bodily function, including, but not limited to, artificial respiration, nutritional
support and hydration, and cardiopulmonary resuscitation;
B. To authorize, or refuse to authorize, any medication or procedure intended to relieve pain, even
though such use may lead to physical damage, addiction, or hasten the moment of, but not
intentionally cause, my death;
C. To authorize my admission to or discharge, even against medical advice, from any hospital,
nursing care facility, or similar facility or service; and

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D. To take any other action necessary to making, documenting, and assuring implementation of
decisions concerning my health care, including, but not limited to, granting any waiver or release
from liability required by any hospital, physician, nursing care provider, or other health care
provider; signing any documents relating to refusals of treatment or the leaving of a facility
against medical advice, and pursuing any legal action in my name, and at the expense of my
estate to force compliance with my wishes as determined by my agent, or to seek actual or
punitive damages for the failure to comply.

EFFECT ON DECLARATION OF A DESIRE FOR A NATURAL DEATH (LIVING WILL)

I understand that if I have a valid Declaration of a Desire for a Natural Death, the instructions contained
in the Declaration will be given effect in any situation to which they are applicable. My agent will have
authority to make decisions concerning my health care only in situations to which the Declaration does
not apply, except to the extent that my Declaration authorizes my agent to make decisions.

ORGAN DONATION
My agent may not consent to the donation of all or any of my tissue or organs for purposes of
transplantation. ______ initials

DEFINITIONS
For the purposes of this document:

- Agent or health care agent means the individual designated in my health care power of attorney
to make health care decisions on my behalf, and includes my successor agent.
- Life-sustaining procedure means a medical procedure or intervention which serves only to
prolong the dying process. Life-sustaining procedure does not include comfort care or tube
feeding.
- Comfort care means treatment, including prescription medication, provided to me for the sole
purpose of alleviating pain, and does not include tube feeding.
- Tube Feeding means nutrition and hydration provided by means of a nasogastric tube or tube
into the stomach, intestines or veins.

STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING TREATMENT

With respect to any Life-Sustaining Treatment, I direct that my wishes as stated in my Declaration of a
Desire for a Natural Death be followed.

STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING TREATMENT

With respect to any Life-Sustaining Treatment, I grant discretion to my agent as follows:

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GRANT OF DISCRETION TO AGENT:
I do not want my life to be prolonged nor do I want life-sustaining treatment to be provided or
continued if my agent believes the burdens of the treatment outweigh the expected benefits. I want my
agent to consider the relief of suffering, my personal beliefs, the expense involved and the quality as
well as the possible extension of my life in making decisions concerning life-sustaining treatment.

My initials in the space following this sentence signify that I understand the above statement and that
the above statement is what I want. _______

STATEMENT OF DESIRES REGARDING TUBE FEEDING

I DO want to receive nutrition and hydration provided by means of a nasogastric tube or tube into the
stomach, intestines or veins.

My initials in the space following this sentence signify that I understand the above statement and that
the above statement is what I want. _______

STATEMENT OF DESIRES REGARDING COMFORT CARE

I DO want to receive comfort care, even if it would prolong the dying process.

My initials in the space following this sentence signify that I understand the above statement and that
the above statement is what I want. _______

ADMINISTRATIVE PROVISIONS
I revoke any prior Health Care Power of Attorney and any provisions relating to health care of any
other prior power of attorney.

This power of attorney is intended to be valid in any jurisdiction in which it is presented.

UNAVAILABILITY OF AGENT
If at any relevant time the Agent or Successor Agents named herein are unable or unwilling to make
decisions concerning my health care, and those decisions are to be made by a guardian, by the Probate
Court, or by a surrogate pursuant to the Adult Health Care Consent Act, it is my intention that the
guardian, Probate Court, or surrogate make those decisions in accordance with my directions as stated
in this document.

SIGNATURE

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By signing here I indicate that I understand the contents of this document and the effect of this GRANT
OF POWERS TO MY AGENT.

I sign my name to this Health Care Power of Attorney on this ________ day of ________________,
________

_____________________________
Charles Henry Thomas
405 Shirley Street
Calhoun Falls, South Carolina 29628

WITNESS STATEMENT
I declare, on the basis of information and belief, that the person who signed or acknowledged this
document, Charles Henry Thomas, is personally known to me, that they signed or acknowledged this
Health Care Power of Attorney in my presence, and that they appear to be of sound mind and under no
duress, fraud, or undue influence. I am not related to Charles Henry Thomas by blood, marriage, or
adoption, either as a spouse, a lineal ancestor, descendant of the parents of Charles Henry Thomas, or
spouse of any of them. I am not directly financially responsible for Charles Henry Thomas's medical
care. I am not entitled to any portion of Charles Henry Thomas's estate upon their decease, whether
under any will or as an heir by intestate succession, nor am I the beneficiary of an insurance policy on
Charles Henry Thomas's life, nor do I have a claim against Charles Henry Thomas's estate as of this
time. I am not Charles Henry Thomas's attending physician, nor an employee of the attending
physician. No more than one witness is an employee of a health facility in which Charles Henry
Thomas is a patient. I am not appointed as Health Care Agent or Successor Health Care Agent by this
document.

Witness No. 1

Signature: _____________________________ Date: ______________

Print Name: ____________________________ Telephone: _____________

Residence Address: ___________________________________________

_____________________________________________________________

Witness No. 2

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Signature: _____________________________ Date: ______________

Print Name: ____________________________ Telephone: _____________

Residence Address: ___________________________________________

_____________________________________________________________

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 NOTARIZATION
(This portion of the document is optional and is not required to create a valid health care power of attorney.)

STATE OF SOUTH CAROLINA

COUNTY OF _____________

The foregoing instrument was acknowledged before me by Charles Henry Thomas this ________ day
of ________________, ________.

___________________________________
Signature

Notary Public for South Carolina

My commission expires: ________________

SEAL

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 RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________ Date: ____________________

2. ____________________________________ Date: ____________________
3. ____________________________________ Date: ____________________
4. ____________________________________ Date: ____________________
5. ____________________________________ Date: ____________________

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