Living Will Declaration Form printable pdf download

Living Will

DECLARATION

This declaration is made this __________ day of__________________________ (month, year).

I, ___________________________________, born on _____________, 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procedures which would only prolong the dying process be withheld or withdrawn, and that I be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 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 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 _______________________________________________________________________

History

(Source: P.A. 85-1209.)

Annotations

Note. This section was Ill.Rev.Stat., Ch. 110 1/2, Para. 703.

Rev 5/2012

Living Will Declaration Form