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Form Rev 133c7e0 - Pa Power Of Attorney For My Health Care - Medical Power Of Attorney Page 3

4. I intend that copies of this document are as effective as the original.

5. My agent will not be entitled to compensation for services performed under this power of attorney, but

he or she will be entitled to reimbursement for all reasonable expenses that result from carrying out any

provision of this power of attorney.

SIGNATURE

I understand the contents of this document and the effect of granting powers to my agent.

Principal's Signature

Michelle R Kane

Principal's Name

January 17, 2018

Date

A STATEMENT BY YOUR WITNESSES

I declare that I personally know you ─ the person who signed this document ─ or I have adequate proof of

your identity, and that you signed or acknowledged this Power of Attorney for My Health Care in front of

me, and that you appear to be of sound mind and under no duress, fraud, or undue influence.

I am an adult and am NOT any of the following:

1. Appointed as your agent or back-up agent.

2. Related to you by blood, marriage, domestic partnership, or adoption, nor a spouse of any such

person.

3. Your health care provider, including the owner or operator of a health, long-term care, or other

residential or community care facility serving you.

4. An employee of your health care provider.

5. Financially responsible for your health care.

6. An employee of your life or health insurance provider.

7. A creditor of yours or entitled to any part of your estate under a will or codicil, trust, insurance policy,

or by operation of intestate succession laws.

8. Entitled to benefit financially in any other way after you die.

First Witness

Witness Signature

Date

Medical Power of Attorney (Rev. 133C7E0)

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Form Rev 133c7e0 - Pa Power Of Attorney For My Health Care - Medical Power Of Attorney Page 3