Vermont Statutory Form With Will To Live Language (Page 4 of 5) in pdf

Vermont Statutory Form With Will To Live Language Page 4

IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and

my Agent(s) to use all lifesaving procedures for myself with none of the above special

conditions applying if there is a chance that prolonging my life might allow my child to be born

alive. I also direct that lifesaving procedures be used even if I am legally determined to be brain

dead if there is a chance that doing so might allow my child to be born alive. Except as I specify

by writing my signature in the box below, no one is authorized to consent to any procedure for

me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above,

medical procedures required to prevent my death are authorized even if they may result in the

death of my unborn child provided every possible effort is made to preserve both my life and the

life of my unborn child.

____________________________________

Signature of Declarant

(attach additional pages as necessary)

The original of this document will be kept at:_________________________________________,

and the following persons and institutions will have signed copies:

In witness whereof, I have hereunto signed my name this ____________ day of

____________________, 20_____.

____________________________________

(signature)

WITNESS STATEMENT

I declare that the principal appears to be of sound mind and free from duress at the time the

Advance Directive is signed and that the principal has affirmed that he or she is aware of the

nature of the document and is signing freely and voluntarily.

First Witness Signature:__________________________________________________________

Residence Address:______________________________________________________________

Second Witness Signature:________________________________________________________

Residence Address:______________________________________________________________

Vermont Statutory Form With Will To Live Language Page 4