Living Will Form Page 2
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1
2Living Will
(Advance Medical Directive)- continued
3. If I cannot give directions concerning the use of such life-sustaining procedures, I want this statement to
be honored by my family and physician(s) as the last expression of my legal right to accept or refuse
medical or surgical treatment and I accept the effects of such refusal.
4. I have also given a Durable Health Care Power of Attorney at the time I made this statement. In case of a
disagreement between this statement and the person to whom I have given the right and power to act for
me, the following statement shall come first:
(Choose one or the other and check ONLY one)
____ This statement shall come before the Durable Health Care Power of Attorney.
____ My Durable Health Care Power of Attorney shall come before this statement.
5. I understand the full importance of this statement and I am emotionally and mentally able to make
this statement.
IN WITNESS HEREOF,
I have signed and acknowledged this statement on this _____day of _______________________, 20_______.
SIGNED: _________________________________________________________________________________
The person signing this statement has been personally known to me and is a person I know to be of
sound mind.
__________________________________________
__________________________________________
Witness
Witness
NOTARY PUBLIC
Louisiana Notary # _____________ ____
My commission expires on: __________
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Parent category: Legal