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LIVING WILL DECLARATION
RELATIVE TO THE USE OF LIFE-SUSTAINING
PROCEDURES
If I should have an incurable or irreversible condition that will result either in
death within a relatively short period of time or a state of permanent unconsciousness
from which, to a reasonable degree of certainty, there can be no recovery, it is my
desire that my life not be prolonged by administration of life-sustaining procedures. If I
am unable to participate in my health care decisions, I direct my attending physician to
withhold or withdraw life-sustaining procedures that merely prolong the dying process
and are not necessary to my comfort or freedom from pain.
DECLARANT SIGNATURE
Signed this
day of
,
.
Signature of Declarant:
Type or Print Name of Declarant:
Address:
WITNESS SIGNATURES
I declare under penalty of perjury that the person who signed this document is
personally known to me to be the Declarant; that the Declarant signed this Declaration
in my presence; or directed another person to sign this document on his/her behalf in
my presence; that I signed this document in the presence of the Declarant and in the
presence of the other undersigned witnesses; that the Declarant appears to be of
sound mind and under no duress, fraud, or undue influence; that I am eighteen (18)
years of age or older; that I am not a health care provider attending the Declarant on
the date of execution of this Declaration; nor am I an employee of the treating health
care provider on the date of execution of this Declaration.
First Witness' Signature:
First Witness' Printed Name:
Address:
Second Witness' Signature:
Second Witness' Printed Name:
Address:
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