Living Will Declaration and Directive to Physicians of *


Notice to Adult Signing This Document: This is an important legal document. This document
directs the medical treatment you are to receive in the event you are unable to participate in your
own medical decisions and you are in a terminal condition. This document may state what kind
of treatment you want or do not want to receive. This document can control whether you live or
die. Prepare this document carefully. If you use this form, read it completely. You may want to
seek professional help to make sure the form does what you intend and is completed without
mistakes. This document will remain valid and in effect until and unless you revoke it. Review
this document periodically to make sure it continues to reflect your wishes. You may amend or
revoke this document at any time by notifying your physician and other health-care providers.
You should give copies of this document to your physician and your family. This form is entirely
optional. If you choose to use this form, please note that the form provides signature lines for
you, the three witnesses whom you have selected and a notary public.

I,* ,being of sound mind, willfully and voluntarily make known my desire that my life not be
artificially prolonged under the circumstances set forth below, and, pursuant to any and all
applicable laws in the State of *, I declare that:

If at any time I should have an incurable injury, disease, or illness which has been certified as
a terminal condition by my attending physician and one additional physician, both of whom
have personally examined me, and such physicians have determined that there can be no
recovery from such condition and my death is imminent, and where the application of life
prolonging procedures would serve only to artificially prolong the dying process, then:

I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally
with only the administration of medication, the administration of nutrition and/or hydration,
or the performance of any medical procedure deemed necessary to provide me with comfort,
care, or to alleviate pain.

If at any time I should have been diagnosed as being in a persistent vegetative state which
has been certified as incurable by my attending physician and one additional physician, both
of whom have personally examined me, and such physicians have determined that there can
be no recovery from such condition, and where the application of life prolonging procedures
would serve only to artificially prolong the dying process, then:

I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally
with only the administration of medication, the administration of nutrition and/or hydration,
or the performance of any medical procedure deemed necessary to provide me with comfort,
care, or to alleviate pain.

In the absence of my ability to give directions regarding my treatment in the above situations,
including directions regarding the use of such life prolonging procedures, then:
It is my intention that this declaration shall be honored by my family, my physician, and any
court of law, as the final expression of my legal right to refuse medical and surgical treatment.
I declare that I fully accept the consequences for such refusal.

If I have any additional directions, I will state them here:


If I have also signed a Health Care Power of Attorney, Appointment of Health Care Agent, or
Health Care Proxy, I direct the person who I have appointed with such instrument to follow
the directions that I have made in this document. I intend for my agent to be treated as I would
be with respect to my rights regarding the use and disclosure of my individually identifiable
health information or other medical records. This release authority applies to any information
governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA),
42 USC 1320d and 45 CFR 160-164.

If I am diagnosed as pregnant, this document shall have no force and effect during my pregnancy.
I understand the full importance of this declaration, and I am emotionally and mentally
competent to make this declaration and Living Will. I also understand that I may revoke this
document at any time.

I publish and sign this Living Will and Directive to Physicians, consisting of * 
typewritten pages ,on * ,20* ,and declare that I do so freely, for the purposes expressed, under no
constraint or undue influence, and that I am of sound mind and of legal age.

*
Declarant 's Signature
*
Printed Name of Declarant

On * ,20* ,in the presence of all of us, the above-named Declarant published and signed this
Living Will and Directive to Physicians, and then at the Declarant 's request, and in the 
Declarant 's presence, and in each other 's presence, we all signed below as witnesses, and we
each declare, under penalty of perjury, that, to the best of our knowledge:

1.The Declarant is personally known to me and, to the best of my knowledge, the Declarant
signed this instrument freely, under no constraint or undue influence, and is of sound mind and
memory and legal age, and fully aware of the possible consequences of this action.

2.I am at least 19 years of age and I am not related to the Declarant in any manner: by blood,
marriage, or adoption.

3.I am not the Declarant 's attending physician, or a patient or employee of the Declarant 's
attending physician; or a patient, physician, or employee of the health care facility in which the
Declarant is a patient, unless such person is required or allowed to witness the execution of this
document by the laws of the state in which this document is executed.

4.I am not entitled to any portion of the Declarant 's estate on the Declarant 's death under the
laws of intestate succession of any state or country, nor under the Last Will and Testament of the
Declarant or any Codicil to such Last Will and Testament.

5.I have no claim against any portion of the Declarant 's estate on the Declarant 's
death.

6.I am not directly financially responsible for the Declarant 's medical care.

7.I did not sign the Declarant 's signature for the Declarant or on the direction of the Declarant,
nor have I been paid any fee for acting as a witness to the execution of this document.


___________________________
Signature of Witness #1
___________________________
Printed name of Witness #1
___________________________
Address of Witness #1
___________________________
Signature of Witness #2
___________________________
Printed name of Witness #2
___________________________
Address of Witness #2
___________________________
Signature of Witness #3
___________________________
Printed name of Witness #3
___________________________
Address of Witness #3


County of _______________
State of _______________
On _______________,20_____,before me personally appeared ____________________,
the Declarant, and ____________________,the first witness,____________________,the
second witness,____________________,the third witness, and, being first sworn on oath
and under penalty of perjury, state that, in the presence of all the witnesses, the Declarant
published and signed the above Living Will Declaration and Directive to Physicians, and then,
at Declarant 's request, and in the presence of the Declarant and of each other, each of the
witnesses signed as witnesses, and stated that, to the best of their knowledge, the Declarant
signed said Living Will Declaration and Directive to Physicians freely, under no constraint
or undue influence, and is of sound mind and memory and legal age and fully aware of the
potential consequences of this action. The witnesses further state that this affidavit is made
at the direction of and in the presence of the Declarant.
___________________________
Signature of Notary Public
___________________________
Printed name of Notary Public
Notary Public,
In and for the County of _______________
State of _______________
My commission expires:_______________Notary Seal