Illinois Living Will Declaration Template printable pdf download

ILLINOIS LIVING WILL DECLARATION

This declaration is made this______day of

(month, year).

being of sound

mind, willfully and voluntarily make known my desires that my moment of death shall

not be artificially 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withdrawn, and that I be permitted to die naturally with only the administration of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 direction 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.

Signature

City, County and State of 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 knowledge 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

America Living Will Registry, LLC. • 2814 Beach Boulevard • St. Petersburg, FL 33707 • 1-866-305-ALWR •

Illinois Living Will Declaration Template