[ This is intended as a sub-page of the Life Extension Society, the
  east coast cryonics group, at http://keithlynch.net/les/ ]

ADVANCE MEDICAL DIRECTIVE OF A CRYONICIST

WHEREAS, I, XXXXXXXXXX, of XXXXXXXXXX, XXXXXXXXXX, believe that the
experimental procedure of cryogenic preservation offers the possibility,
which is speculative, of eventual restoration of my human remains to life
and health; and

WHEREAS, I desire that my human remains, including at a minimum my brain
and brain stem, be preserved by the experimental procedure of cryogenic
preservation; and

WHEREAS, I have executed separate instruments, entitled "Last Will and
Testament," "Consent to Cryopreservation," "Authorization of Anatomical
Donation," and "Cryopreservation Agreement," whereby I have arranged for
and directed that upon my legal death my human remains be delivered for
the experimental procedure of cryogenic preservation to the XXXXXXXXXX
Foundation, Inc., a XXXXXXXXXX Corporation with principal offices
in XXXXXXXXXX, XXXXXXXXXX, including any agent of the XXXXXXXXXX
Foundation; and

WHEREAS, I believe that the timeliness and thoroughness of the
experimental procedure of cryogenic preservation and the possibility of
my human remains being restored to life and health will be enhanced if
damage to or deterioration of my tissues, especially my brain and brain
stem, from disease, pre-mortem ischemia, post-mortem ischemia, and
autopsy is avoided or minimized up to the time that the cryogenic
preservation of my human remains can begin; and

WHEREAS, I desire that whenever my life expectancy is limited, the
primary purposes of any health care decision be to avoid or minimize
damage to or deterioration of my tissues, especially my brain and brain
stem, from disease, pre-mortem ischemia, post-mortem ischemia, and
autopsy up to the time that the cryogenic preservation of my human
remains can begin, and otherwise to enable timeliness and thoroughness
in the ensuing procedure of cryogenic preservation of my human
remains; and

WHEREAS, I desire to appoint and empower an Agent to make health care
decisions on my behalf whenever I have been determined to be incapable
of making an informed decision about providing, withholding, or
withdrawing medical treatment.

NOW THEREFORE, I, XXXXXXXXXX, of XXXXXXXXXX, XXXXXXXXXX, willfully and
voluntarily make known my desires and do hereby declare:

1.  Primary Purposes of Health Care Decisions on My Behalf When My Life
Expectancy Is Limited.  I direct that the primary purposes of any health
care decision, as defined in paragraph 6.c. of this advance directive,
that is made on my behalf when my life expectancy is limited, as defined
in paragraph 6.g. of this advance directive, be as follows:

a.  To avoid or minimize damage to and deterioration of my tissues,
especially my brain and brain stem, from disease, pre-mortem ischemia,
post-mortem ischemia, and autopsy up to the time that the cryogenic
preservation of my human remains can begin, as defined in paragraph
6.h. of this advance directive.

b.  Otherwise to enable timeliness and thoroughness in the ensuing
procedure of cryogenic preservation of my human remains.

I so direct in full knowledge that a health care decision made before the
time that the cryogenic preservation of my human remains can begin may be
different from a health care decision made at the time that the cryogenic
preservation of my human remains can begin.  Furthermore, I so direct
even though the medical treatment, as defined in paragraph 6.e. of this
advance directive, that results from such health care decision may not
be medically necessary or may inadvertently hasten my death.

2.  Health Care Providers.

a.  Direction to Cooperate.  I direct that my attending physician, other
medical authorities responsible for my medical care, and their agents
comply with this advance directive, cooperate (including cooperating in
preparations for the cryogenic preservation of my human remains) with
the XXXXXXXXXX Foundation and any agent of the XXXXXXXXXX Foundation,
as defined in paragraph 6.a. of this advance directive, and, whenever I
have been determined to be incapable of making an informed decision, as
defined in paragraph 6.d. of this advance directive, about providing,
withdrawing, or withholding medical treatment, adhere to the health care
decisions made on my behalf by my Agent, named hereinafter.

b.  Authorization of Medical Treatments.

1.  I authorize my health care providers, when my life expectancy is
limited, to provide medical treatment(s) as appropriate to avoid or
minimize damage to and deterioration of my tissues, especially my brain
and brain stem, from disease, pre-mortem ischemia, post-mortem ischemia,
and autopsy up to the time that the cryogenic preservation of my human
remains can begin, and otherwise to enable timeliness and thoroughness
in the ensuing procedure of cryogenic preservation of my human remains.
I so authorize in full knowledge that the cryogenic preservation of my
human remains may be inconsistent with traditional medical practice.

2.  I direct that medical treatment be provided if deemed necessary
to give me comfort care or to alleviate pain, unless such provision
conflicts with the primary purposes of health care decisions as specified
in paragraph 1 of this advance directive.

c.  Attending Physician.  I direct that XXXXXXXXXX, M.D., of XXXXXXXXXX,
XXXXXXXXXX, serve as my attending physician if he is available and is
willing and able to so serve.  If XXXXXXXXXX is not available or is
unwilling or unable to so serve, I direct that a physician who is willing
to comply with this advance directive within the limits of his authority
serve as my attending physician.

d.  Determination That I Am Incapable of Making an Informed Decision
about Providing, Withholding, or Withdrawing Medical Treatment.  Any
determination that I am incapable of making an informed decision shall
be made by my attending physician and a second physician or licensed
clinical psychologist after a personal examination of me, shall take
effect immediately, shall be communicated promptly to my Agent orally or
in writing, shall be certified in writing promptly and every 180 days
thereafter, and shall be in effect until withdrawn by my attending
physician or the second physician or licensed clinical psychologist.
However, if my death is imminent, as defined in paragraph 6.f. of this
advance directive, and such determination has not been made heretofore,
and for so long as a second physician or licensed clinical psychologist
is not available, then such determination may be made solely by my
attending physician.  Neither a determination under this paragraph, nor
a failure to make, communicate, or certify such determination, shall
modify my express directions in this advance directive.

e.  Release from Liability; Indemnification.  No person who relies in
good faith upon any representations by my Agent or, in the absence
of instructions from my Agent, in good faith provides, withholds, or
withdraws medical treatment for the purpose of carrying out or attempting
to carry out my instructions in this advance directive, shall be liable
to me, my estate, my heirs or assigns for recognizing my Agent's
authority or for carrying out such instructions.  I hereby agree to
indemnify such person against any and all costs and expenses incurred
as a result of recognizing my Agent's authority or as a result of
carrying out or attempting to carry out such instruction, except to the
extent that either the XXXXXXXXXX Foundation is responsible for such
costs and expenses pursuant to the Cryopreservation Agreement executed
between me and the XXXXXXXXXX Foundation, or that another third party is
responsible for such costs and expenses, and except that funds passing
to the XXXXXXXXXX Foundation from my estate or as a consequence of
any contract entered into by me shall not be used to pay such costs
and expenses.

3.  Agent.  As further specified below, I appoint and empower an Agent,
named hereinafter, to make health care decisions on my behalf whenever I
have been determined to be incapable of making an informed decision about
providing, withholding, or withdrawing medical treatment.

a.  Naming of Agent.  I hereby appoint XXXXXXXXXX, of XXXXXXXXXX,
XXXXXXXXXX to serve as my Agent.  I direct that no surety be required
of my Agent as such.

b.  Grant of Powers to Agent.  I hereby grant to my Agent, named above,
full power and authority to make health care decisions on my behalf as
described in this advance directive whenever I have been determined in
accordance with paragraph 2.d. of this advance directive to be incapable
of making an informed decision about providing, withholding, or
withdrawing medical treatment.  My Agent's authority hereunder is
effective so long as I am incapable of making an informed decision.
The powers of my Agent shall include the following:

1.  To request, consent to, refuse, or withdraw consent to any type of
medical treatment on my behalf.  This authorization specifically includes
the power to request or consent to the administration of dosages of
pain-relieving medication in excess of standard dosage in an amount
sufficient to relieve pain, even if such medication carries the risk
of addiction or may inadvertently hasten my death.

2.  To request, receive, and review any information, verbal or written,
regarding my physical or mental health, including but not limited to,
medical and hospital records, and to consent to or refuse the disclosure
of this information.

3.  To employ and discharge my health care providers.

4.  To direct or authorize my admission to, discharge from, or transfer
to or from any nursing home, adult home, hospital, other medical care
facility, my place of residence, any other private residence, any other
facility offering hospice, nursing, or long term care services, a
facility for the cryogenic preservation of human remains, or any other
place, even against medical advice.

5.  To take any lawful actions that may be necessary to carry out these
decisions, including the granting of releases of liability to health
care providers, the signing of any documents on my behalf related to my
medical treatment or the refusal or withdrawing thereof, and contracting
on my behalf for any health care related service or facility.

c.  Instructions to Agent.  I direct that my Agent, in making any health
care decision whenever I have been determined to be incapable of making
an informed decision about providing, withholding, or withdrawing medical
treatment, take into consideration my medical diagnosis and prognosis and
the likely damage to and deterioration of my tissues, especially my brain
and brain stem, from disease, pre-mortem ischemia, post-mortem ischemia,
and autopsy with and without the treatment, together with any information
provided by my physicians as to the intrusiveness, pain, risks and side
effects associated with medical treatment or non-treatment.  My Agent
shall not authorize a course of treatment that he knows, or upon
reasonable inquiry ought to know, is inconsistent with the principal
purposes specified in paragraph 1 of this advance directive.  If my
Agent cannot determine what treatment choice I would have made on my
own behalf, then my Agent shall make a choice for me based upon what
he believes to be in my best interests, consistent with such purposes.

d.  Reimbursement; Waiver of Liability; Indemnification.  My Agent shall
not be entitled to compensation for services performed under this advance
directive, but he shall be entitled to reimbursement for all reasonable
costs and expenses incurred as a result of carrying out or attempting
to carry out any provisions of this advance directive.  My agent shall
not be liable to me, my estate, my heirs or assigns for any costs and
expenses of treatment or non-treatment pursuant to his authorization,
based solely on that authorization, and I hereby agree to indemnify my
Agent against any and all such costs and expenses, except to the extent
that either the XXXXXXXXXX Foundation is responsible for such costs and
expenses, pursuant to the Cryopreservation Agreement executed between me
and the XXXXXXXXXX Foundation, or that another third party is responsible
for such costs and expenses, and except that funds passing to the
XXXXXXXXXX Foundation from my estate or as a consequence of any contract
entered into by me shall not be used to pay such costs and expenses.

4.  Specific Instructions For When My Death Is Imminent.

a.  I direct that the XXXXXXXXXX Foundation, XXXXXXXXXX, and XXXXXXXXXX
be notified immediately of my medical condition.

b.  I direct that, up to the time that the cryogenic preservation of
my human remains can begin, I be kept alive or resuscitated or my
resuscitation continue to be attempted, and that my death not be
pronounced.  Such efforts should be undertaken if necessary through the
application of artificial life-prolonging procedures, as defined in
paragraph 6.b. of this advance directive.

c.  I direct that, once the time that the cryogenic preservation of my
human remains can begin is reached, I be permitted to die.  Specifically,
I direct that any artificial life-prolonging procedures be withheld or
be withdrawn promptly and that my legal death be declared promptly upon
cessation of vital functions.  In the absence of my ability to give
directions regarding the use of artificial life-prolonging procedures,
it is my intention that this advance directive be honored by my family
and attending physician as the final expression of my legal right to
refuse medical treatment and accept the consequences of such refusal.

5.  Miscellaneous Provisions.

a.  This advance directive shall not terminate in the event of my
disability.

b.  I revoke any prior advance medical directive.

c.  This advance directive is intended to be valid in any jurisdiction in
which it is presented.

d.  The provisions of, and powers delegated under, this advance directive
are separable, so that the invalidity of one or more provisions or powers
shall not affect any others.

6.  Definitions.

a.  The term "agent of the XXXXXXXXXX Foundation" means an agent,
representative, contractor, employee, volunteer, assistant, associate,
physician, or other person authorized to act on behalf of the XXXXXXXXXX
Foundation.

b.  The term "artificial life-prolonging procedure" means a mechanical
or other procedure that artificially replaces, enhances, or assists a
failing or failed vital function, and may include, but is not necessarily
limited to, artificial respiration, artificially administered nutrition
and hydration, and cardiopulmonary resuscitation.

c.  The term "health care decision" means any decision about providing,
withholding, or withdrawing medical treatment, selecting health care
providers, or selecting the place of medical treatment.

d.  The term "incapable of making an informed decision" means unable to
understand the nature, extent and probable consequences of a proposed
health care decision or unable to make a rational evaluation of the risks
and benefits of a proposed health care decision as compared with the
risks and benefits of alternatives to that decision, or unable to
communicate such understanding in any way.

e.  The term "medical treatment" means any type of medical care,
treatment, surgical procedure, diagnostic procedure, other medical
procedure, oral or intravenous medication (including, but not necessarily
limited to, anti-coagulants, thrombolytic agents, and/or anti-acids),
and the use of mechanical or other procedures that affect any bodily
function, including, but not limited to, artificial lowering of body
temperature and artificial life-prolonging procedures.

f.  The term "my death is imminent" means that failure of a vital
function or functions is imminent, or such failure has taken place
and I am being kept alive with artificial life-prolonging procedures.

g.  The term "my life expectancy is limited" means that I am in a chronic
vegetative state, or my condition is terminal and my attending physician
has determined that no medical treatment can afford recovery from such
condition, even though the provision of an artificial life-prolonging
procedure or procedures could protract the dying process.

h.  The term "the time that the cryogenic preservation of my human
remains can begin" means the time that both:

1.  An agent of the XXXXXXXXXX Foundation is available and states that
he or she is prepared to initiate cryogenic preservation of my human
remains; and

2.  A person authorized to pronounce my legal death is available and
prepared to do so.

By signing below, I indicate that I am emotionally and mentally competent
to make this advance directive and that I understand the purpose and
effect of this document.

Dated this ________ day of ________________, 19____.
______________________________

XXXXXXXXXX

Address:
______________________________

______________________________

The declarant signed the foregoing advance directive in my presence.
I am not the spouse or a blood relative of the declarant.

Signed:
______________________________

Witness

Name:
______________________________

Address:
______________________________

______________________________

Signed:
______________________________

Witness
Name:
______________________________

Address:
______________________________

______________________________

Signed:
______________________________

Witness
Name:
______________________________

Address:
______________________________

______________________________