Fillable Statutory Advance Directive (Page 4 of 8) in pdf

Statutory Advance Directive Page 4

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(Do not sign until in the presence of two qualified witnesses; see below)

Signed: ______________________________________________________________

Date: ________________________________________________________________

Residence: ____________________________________________________________

Living Will Witnesses:

8. The declarant has been personally known to me, and I believe (him/her) to be of sound mind.

I did not sign the declarant’s signature above for or at the direction of the declarant. I am

not a parent, spouse, or child of the declarant. I am not entitled to any part of the

declarant’s estate or directly financially responsible for the declarant’s medical care. I am

a legally competent individual and at least eighteen (18) years of age.

Witness: ____________________________________ Date: ____________________

Printed Name: _______________________________

Address: ______________________________________________________________

10.

Witness: ____________________________________ Date: ____________________

Printed Name: _______________________________

Address: ______________________________________________________________

OPTION B:

LIFE PROLONGING PROCEDURES DECLARATION

(Terminal Treatment Request):

(Complete this section only if you wish to request life prolonging medical treatment if terminally

ill. If you know you want to refuse terminal treatment, or are unsure, return to the “terminal

treatment refusal” section, above)

Declaration made this _________ day of ___________________________ 20_______.

11. I, ____________________________________________________________, being at least

18 years of age and of sound mind, willfully and voluntarily make known my desire that

if at any time I have an incurable injury, disease, or illness determined to be a terminal

condition I request the use of life prolonging procedures that would extend my life. This

includes appropriate nutrition and hydration, the administration of medication, and the

performance of all other effective medical procedures necessary to extend my life, to

provide comfort care, or to alleviate pain.

Statutory Advance Directive Page 4

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