Colorado Durable Power Of Attorney For Health Care Will To Live Form (Page 4 of 4) in pdf

Colorado Durable Power Of Attorney For Health Care Will To Live Form Page 4

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 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

I understand the full import of this declaration and I am emotionally and mentally competent to

make this declaration.

Signed this ____________________day of ___________________________, 20_______.

(Signature)____________________________________________________________________

WITNESSES

The person whose signature appears above, who seems to us to be of sound mind and under no

duress, signed this document in our presence.

First Witness Signature:__________________________________________________________

Residence Address:______________________________________________________________

Second Witness Signature:________________________________________________________

Residence Address:______________________________________________________________

Form prepared 2001

*clerical changes made 11/05

Page 4 of 4

Colorado Durable Power Of Attorney For Health Care Will To Live Form Page 4