Statutory Advance Directive Page 5
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8Additional Instructions:
12. I also wish to add the following additional instructions: ___________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Declaration Intent:
13. In the absence of my ability to give directions regarding the use of life prolonging
procedures, it is my intention that this declaration be honored by my family and physician
as the final expression of my legal right to request medical or surgical treatment and I
accept the consequences of the request. I understand the full import of this declaration.
(Do not sign until in the presence of two qualified adult witnesses; see below)
14.
Signed: ______________________________________________________________
Date: ________________________________________________________________
Residence: ____________________________________________________________
Living Will Witnesses:
15. 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.
16.
Witness: ____________________________________ Date: ____________________
Printed Name: _______________________________
Address: ______________________________________________________________
17.
Witness: ____________________________________ Date: ____________________
Printed Name: _______________________________
Address: ______________________________________________________________
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