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              DURABLE POWER OF ATTORNEY FOR HEALTH CARE

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              WARNING TO PERSON EXECUTING THIS DOCUMENT

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

THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR AGENT (THE
ATTORNEY IN FACT) THE POWER TO MAKE HEALTH CARE DECISIONS FOR
YOU. YOUR AGENT MUST ACT CONSISTENTLY WITH YOUR DESIRES AS
STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN.

EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THIS DOCUMENT
GIVES YOUR AGENT THE POWER TO CONSENT TO YOUR DOCTOR NOT GIVING
TREATMENT OR STOPPING TREATMENT NECESSARY TO KEEP YOU ALIVE.

NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE
MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF SO LONG AS
YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR
DECISION.  IN ADDITION, NO TREATMENT MAY BE GIVEN TO YOU OVER
YOUR OBJECTION AT THE TIME, AND HEALTH CARE NECESSARY TO KEEP
YOU ALIVE MAY NOT BE STOPPED OR WITHHELD IF YOU OBJECT AT THE
TIME.

THIS DOCUMENT GIVES YOUR AGENT AUTHORITY TO CONSENT, TO REFUSE
TO CONSENT, OR TO WITHDRAW CONSENT TO ANY CARE, TREATMENT,
SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL
OR MENTAL CONDITION.  THIS POWER IS SUBJECT TO ANY STATEMENT OF
YOUR DESIRES AND ANY LIMITATIONS THAT YOU INCLUDE IN THIS
DOCUMENT.  YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT
THAT YOU DO NOT DESIRE.  IN ADDITION, A COURT CAN TAKE AWAY THE
POWER OF YOUR AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU IF
YOUR AGENT (1) AUTHORIZES ANYTHING THAT IS ILLEGAL, (2) ACTS
CONTRARY TO YOUR KNOWN DESIRES, OR (3) WHERE YOUR DESIRES ARE
NOT KNOWN, DOES ANYTHING THAT IS CLEARLY CONTRARY TO YOUR BEST
INTERESTS.

THE POWERS GIVEN BY THIS DOCUMENT WILL EXIST FOR AN INDEFINITE
PERIOD OF TIME UNLESS YOU LIMIT THEIR DURATION IN THIS DOCUMENT.

YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY OF YOUR AGENT BY
NOTIFYING YOUR AGENT OR YOUR TREATING DOCTOR, HOSPITAL, OR OTHER
HEALTH CARE PROVIDER ORALLY OR IN WRITING OF THE REVOCATION.

YOUR AGENT HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO
CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS
DOCUMENT.

UNLESS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THIS DOCUMENT
GIVES YOUR AGENT THE POWER AFTER YOU DIE TO (1) AUTHORIZE AN
AUTOPSY, (2) DONATE YOUR BODY OR PARTS THEREOF FOR TRANSPLANT OR
THERAPEUTIC OR EDUCATIONAL OR SCIENTIFIC PURPOSES, AND (3)
DIRECT THE DISPOSITION OF YOUR REMAINS.

THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF ATTORNEY FOR
HEALTH CARE.

YOU SHOULD CAREFULLY READ AND FOLLOW THE WITNESSING PROCEDURE
DESCRIBED AT THE END OF THIS FORM.  THIS DOCUMENT WILL NOT BE
VALID UNLESS YOU COMPLY WITH THE WITNESSING PROCEDURE.

IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.

YOUR AGENT MAY NEED THIS DOCUMENT IMMEDIATELY IN CASE OF AN
EMERGENCY THAT REQUIRES A DECISION CONCERNING YOUR HEALTH CARE. 
EITHER KEEP THIS DOCUMENT WHERE IT IS IMMEDIATELY AVAILABLE TO
YOUR AGENT AND ALTERNATE AGENTS OR GIVE EACH OF THEM AN EXECUTED
COPY OF THIS DOCUMENT.  YOU MAY ALSO WANT TO GIVE YOUR DOCTOR AN
EXECUTED COPY OF THIS DOCUMENT.

DO NOT USE THIS FORM IF YOU ARE A COURT-APPOINTED CONSERVATEE
AND YOU WANT TO APPOINT YOUR CONSERVATOR AS YOUR AGENT.  YOU CAN
DO THAT ONLY IF THE APPOINTMENT DOCUMENT INCLUDES A CERTIFICATE
OF YOUR ATTORNEY.

 1.  DESIGNATION OF HEALTH CARE AGENT.  I,                 , of
Rock Island County, Illinois, do hereby designate and appoint   
              as my attorney in fact (agent) to make health care
decisions for me as authorized in this document.  For the
purposes of this document, "health care decision" means consent,
refusal of consent, or withdrawal of consent to any care,
treatment, service, or procedure to maintain, diagnose, or treat
an individual's physical or mental condition.

2.  CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE.  By
this document I intend to create a durable power of attorney for
health care.  This power of attorney shall not be affected by my
subsequent incapacity.

3.  GENERAL STATEMENT OF AUTHORITY GRANTED.  Subject to any
limitations in this document, I hereby grant to my agent full
power and authority to make health care decisions for me to the
same extent that I could make such decisions for myself if I had
the capacity to do so.  In exercising this authority, my agent
shall make health care decisions that are consistent with my
desires as stated in this document or otherwise made known to my
agent, including, but not limited to, my desires concerning
obtaining or refusing or withdrawing life-prolonging care,
treatment, services, and procedures.

4.  STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. 
In exercising the authority under this durable power of attorney
for health care, my agent shall act consistently with my desires
as stated below and is subject to the special provisions and
limitations stated below:

     (a) Statement of desires concerning life-prolonging care,
treatment, services and procedures:

_________________________________________________________________
__

_________________________________________________________________
__

_________________________________________________________________
__

     (b) Additional statement of desires, special provisions and
limitations:

_________________________________________________________________
__

_________________________________________________________________
__

_________________________________________________________________
__

5.  INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY
PHYSICAL OR MENTAL HEALTH.  Subject to any limitations in this
document, my agent has the power and authority to do all of the
following:

     (a) Request, review, and receive any information, verbal or
written, regarding my physical or mental health, including, but
not limited to, medical and hospital records.

     (b) Execute on my behalf any releases or other documents
that may be required in order to obtain this information.

     (c) Consent to the disclosure of this information.

6.  SIGNING DOCUMENTS, WAIVERS, AND RELEASES.  Where necessary
to implement the health care decisions that my agent is
authorized by this document to make, my agent has the power and
authority to execute on my behalf all of the following:

     (a) Documents titled or purporting to be a "Refusal to
Permit Treatment" and "Leaving Hospital Against Medical Advice."

     (b) Any necessary waiver or release from liability required
by a hospital physician.

7.  AUTOPSY; ANATOMICAL GIFTS; DISPOSITION OF REMAINS. Subject
to any limitations in this document, my agent has the power and
authority to do all of the following:

     (a) Authorize an autopsy.

     (b) Make a disposition of a part or parts of my body.

     (c) Direct the disposition of my remains.

8.  DURATION. Unless you specify otherwise in the space below,
this power of attorney will exist for an indefinite period of
time.

This durable power of attorney for health care expires on
___________.

9.  DESIGNATION OF ALTERNATIVE AGENTS.  If the person designated
as my agent in Paragraph 1 is not available or becomes
ineligible to act as my agent to make health care decisions for
me or loses the mental capacity to make health care decisions
for me, or if I revoke that person's appointment or authority to
act as my agent to make health care decisions for me, then I
designate and appoint                        to serve as my
agent to make health care decisions for me as authorized in this
document.

10. NOMINATION OF CONSERVATOR OF PERSON.  If a Conservator of
the Person is to be appointed for me, I nominate the following
person to serve as conservator of the person:             .  If 
                  is unable or unwilling for any reason to act,
then I nominate                   to serve as conservator of the
person.

11. PRIOR DESIGNATIONS REVOKED.  I revoke any prior durable
power of attorney for health care.



                   DATE AND SIGNATURE OF PRINCIPAL

I sign my name to this Durable Power of Attorney for Health Care
on _________________, 19___, at Moline, Illinois.



______________________________ Name                             
 (THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED
BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR
ACKNOWLEDGE YOUR SIGNATURE.  IF YOU HAVE ATTACHED ANY ADDITIONAL
PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE
ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS POWER
OF ATTORNEY.)

                        STATEMENT OF WITNESSES

I declare under penalty of perjury under the laws of ***Q5***
that the person who signed or acknowledged this document is
personally known to me (or proved to me on the basis of
convincing evidence) 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 health care provider, an employee of a health care
provider, the operator of a community care facility, nor an
employee of an operator of a community care facility.



______________________________ Signature

 ______________________________ Print Name

 Date:_________________________



Residence Address:

______________________________

 ______________________________



 ______________________________ Signature

 ______________________________ Print Name

 Date:_________________________



Residence Address:

______________________________

 ______________________________



 (AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE
FOLLOWING DECLARATION.)

I further declare under penalty of perjury under the laws of
Illinois 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 by operation
of law.



Signature: _____________________________



Signature: _____________________________





STATE OF ILLINOIS       )                    :   ss. COUNTY OF
ROCK ISLAND       )



On the _________ day of ________________, 19___, before me, the
undersigned, a Notary Public in and for said County and State,
personally appeared                       , known to me (or
proved to me on the basis of satisfactory evidence) to be the
person whose name is subscribed to the within instrument, and
acknowledged to me that he/she executed the same.

WITNESS my hand and official seal.



______________________________ NOTARY PUBLIC