Illinois Living Will Act

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Illinois Living Will Act
(Illinois Compiled Statutes, 755 ILCS 35/1 et seq.
DECLARATION
This declaration is made this
day of
(month, year).
I,
being of sound mind, willfully and
voluntarily make known my desires that my moment of death shall not be artifically postponed.
If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal
condition by my attending physician who has personally examined me and has determined that my death is
imminent except for death delaying procedures, I direct that such procedures which would only prolong the
dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of
medication, sustenance, or the performance of any medical procedure deemed necessary by my attending
physician to provide me with comfort care.
In the absence of my ability to give directions regarding the use of such death delaying procedures, it is
my intention that this declaration shall be honored by my family and physician as the final expression of my legal
right to refuse medical or surgical treatment and accept the consequences from such refusal.
Signed
City, County and State Residence
The declarant is personally known to me and I believe him or her to be of sound mind. I saw the declarant sign
the declaration in my presence (or the declarant acknowledged in my presence that he or she had signed the
declaration) and I signed the declaration as a witness in the presence of the declarant. I did not sign the declarant’s
signature above for or at the direction of the declarant. At the date of this instrument, I am not entitled to any
portion of the estate of the declarant according to the laws of intestate succession or, to the best of my knowl-
edge and belief, under any will of declarant or other instrument taking effect at declarant’s death, or directly
financially responsible for declarant’s medical care.
Witness
Witness
For copies, contact the Illinois Department on Aging
One Natural Resources Way, #100, Springfield, IL 62702-1271
Senior HelpLine at
1-800-252-8966, 1-888-206-1327 (TTY)
The Illinois Department on Aging does not discriminate in admission to programs or treatment of employment in programs or activities in compliance
with appropriate State and Federal Statutes. If you feel you have been discriminated against, you have a right to file a complaint with the Illinois
Department on Aging. For information, call the Senior HelpLine at 1-800-252-8966, 1-888-206-1327 (TTY).
Printed by Authority State of Illinois, Department on Aging
IL-402-0764 (Rev. 6/11, 16M)

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