Wills and Estates

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Sample LIVING Will DECLARATION

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 20th day of August, yr19961. Signature of Declarant:                                                                                       2 Type or Print Name of Declarant: John B. Quiland3 Address: 4420 Hickory Bluff Dr.4               Rock Island, IL5 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:                                                                                    6 First Witness' Printed Name: Bernice D. Hanrahan7 Address: 221 4th St., Rock Island IL8 Second Witness' Signature:                                                                               9 Second Witness' Printed Name: Dorene A. Buckstern10 Address: 482 12th St., Rock Island, IL11   This is not a substitute for legal advice.  An attorney must be consulted. Copyright © 1994 - 2015 by LAWCHEK, LTD.

 

ADDITIONAL WITNESS SIGNATURE (AT LEAST ONE OF THE TWO WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION)      I further declare under penalty of perjury that I am not related to the Declarant by blood, marriage or adoption within the third degree of consanguinity. Signature:                                                                                                        12 Signature:                                                                                                        13 OR NOTARY State of Illinois14 ) )ss County of Rock Island14 ) On this 20th15 day of August15, in the year 199615, before me the undersigned, a Notary Public in and for the State of Illinois14, personally appeared John B. Quiland16 (the Declarant) personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument; and acknowledged that he or she executed it as his or her voluntary act or deed.      I declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence, and that I am satisfied as to the genuineness and due execution of this document. (NOTARY SEAL) Signature of Notarial Officer                                                            17         This is not a substitute for legal advice.  An attorney must be consulted. Copyright © 1994 - 2021 by LAWCHEK, LTD.

 

The form above is an example of how a typical Living Will form may be completed.

1. The date on which the Living Will is signed.

2. The signature of the Declarant.

3. The printed name of the Declarant.

4. The street address of the Declarant.

5. The city and state in which the Declarant resides.

6. The signature of the first witness.

7. The printed name of the first witness.

8. The address of the first witness.

9. The signature of the second witness.

10. The printed name of the second witness.

11. The address of the second witness.

12. The signature of the first witness.

13. The signature of the second witness.

14. The state and county in which the document is notarized.

15. The date on which the document is notarized.

16. The name of the Declarant.

17. The signature of the notary.

 

 

This is not a substitute for legal advice.  An attorney must be consulted.
Copyright © 1994 - 2021 by LAWCHEK, LTD.

 

This is not a substitute for legal advice. An attorney must be consulted.