Declaration Of Living Will Form, Durable Power Of Attorney For Health Care Template (Page 3 of 4) in pdf

Declaration Of Living Will Form, Durable Power Of Attorney For Health Care Template Page 3

Section 2:

Artificial Nutrition and Hydration

I understand that Arkansas law requires me to make my wishes regarding artificial nutrition and hydration

known separately from the above directions. Therefore, by initialing the appropriate line(s) below, I

specifically:

_______ DIRECT that artificial nutrition may be withheld or withdrawn after consultation

with my attending physician.

_______ DIRECT that artificial hydration may be withheld or withdrawn after consultation

with my attending physician.

SIGNED this _____________ day of ______________________________, 20____.

________________________________________

Signature

We, the undersigned, do hereby certify that the Declarant, ______________________________

subscribed this Declaration of Living Will in our presence, and we, at his or her request, in his or her

presence, and in the presence of each other, signed as attesting witnesses, and we do further certify that

the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without undue

influence, fraud or restraint and that his or her signature was voluntary.

____________________________________

_____________________________________

Witness

____________________________________

_____________________________________

Address

____________________________________

_____________________________________

City, State and Zip Code

Page 2

Declaration Of Living Will Form, Durable Power Of Attorney For Health Care Template Page 3