Illinois Living Will Declaration Template (Page 3 of 8) in pdf

Effective upon my death, my agent has the full power to make an anatomical gift of the

following (initial one):

_______ Any organ.

_______ Specific organs: __________________________________________________

(THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS

POSSIBLE SO THAT YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY

DECISION YOU COULD MAKE TO OBTAIN OR TERMINATE ANY TYPE OF

HEALTH CARE, INCLUDING WITHDRAWAL OF FOOD AND WATER AND

OTHER LIFE-SUSTAINING MEASURES, IF YOUR AGENT BELIEVES SUCH

ACTION WOULD BE CONSISTENT WITH YOUR INTENT AND DESIRES. IF YOU

WISH TO LIMIT THE SCOPE OF YOUR AGENT'S POWERS OR PRESCRIBE

SPECIAL RULES OR LIMIT THE POWER TO MAKE AN ANATOMICAL GIFT,

AUTHORIZE AUTOPSY OR DISPOSE OF REMAINS, YOU MAY DO SO IN THE

FOLLOWING PARAGRAPHS.)

2. The powers granted above shall not include the following powers or shall be subject to

the following rules or limitations (here you may include any specific limitations you

deem appropriate, such as: your own definition of when life-sustaining measures should

be withheld; a direction to continue food and fluids or life-sustaining treatment in all

events; or instructions to refuse any specific types of treatment that are inconsistent with

your religious beliefs or unacceptable to you for any other reason, such as blood

transfusion, electro-convulsive therapy, amputation, psychosurgery, voluntary admission

to a mental institution, etc.):

________________________________________________________________________

(THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR

IMPORTANCE. FOR YOUR CONVENIENCE IN DEALING WITH THAT SUBJECT,

SOME GENERAL STATEMENTS CONCERNING THE WITHHOLDING OR

REMOVAL OF LIFE-SUSTAINING TREATMENT ARE SET FORTH BELOW.

IFYOU AGREE WITH ONE OF THESE STATEMENTS, YOU MAY INITIAL THAT

STATEMENT; BUT DO NOT INITIAL MORE THAN ONE):

I do not want my life to be prolonged nor do I want life-sustaining treatment to be

provided or continued if my agent believes the burdens of the treatment outweigh the

expected benefits. I want my agent to consider the relief of suffering, the expense

involved and the quality as well as the possible extension of my life in making decisions

concerning life-sustaining treatment.

Initialed ________

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

Illinois Living Will Declaration Template Page 3