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.
You acknowledge that LAWCHEK™ owns all rights, title, and interest, including and without limitation all intellectual property rights (as defined below), in and to the forms and information (including LAWCHEK™ website and brand features, including implied licenses, and excluding items licensed by LAWCHEK™ from third parties and excluding any third party property), and that you will not acquire any rights, title, or interest in or to the legal forms or information or copyrights, except as expressly set forth on the site in regard to using the legal forms for information gathering purposes. You will not modify, adapt, translate, prepare derivative works from, decompile, reverse engineer, disassemble or otherwise attempt to derive source copyright from any LAWCHEK™ services or documentation, or create or attempt to create a substitute or similar service or product through use of or access to this website or proprietary information related thereto. You will not remove, obscure, or alter the LAWCHEK™ copyright notice, brand features, or other proprietary rights notices affixed to or contained within any LAWCHEK™ services, software, or documentation (including without limitation the use of LAWCHEK™ brand features with online legal forms, web hosting services, website html codes, or LAWCHEK™ website copyrights, as applicable). "Intellectual Property Rights" means any and all rights existing from time-to-time under patent law, copyright law, semiconductor chip protection law, moral rights law, trade secret law, trademark law, unfair competition law, publicity rights law, privacy rights law, and any and all other proprietary rights, as well as, any and all applications, renewals, extensions, restorations, and re-instatements thereof, now or hereafter in force and effect worldwide.
This is not a substitute for legal advice. An attorney must be consulted. To find an attorney in your area, please CLICK HERE.
Sample LIVING Will DECLARATION
This
is not a substitute for legal advice. An
attorney must be consulted. |
This
is not a substitute for legal advice. An
attorney must be consulted. |
The form above is an example of how a typical Living Will form may be completed.
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The date on which the Living Will is signed.
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The signature of the Declarant.
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The printed name of the Declarant.
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The street address of the Declarant.
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The city and state in which the Declarant resides.
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The signature of the first witness.
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The printed name of the first witness.
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The address of the first witness.
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The signature of the second witness.
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The printed name of the second witness.
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The address of the second witness.
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The signature of the first witness.
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The signature of the second witness.
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The state and county in which the document is notarized.
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The date on which the document is notarized.
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The name of the Declarant.
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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.