Living Will Form Tennessee Page 2
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4by operation of law then existing; that we are not the attending physician, an employee of the attending physician or a health facility in
which the declarant is a patient; and that we are not persons who, at the present time, have a claim against any portion of the estate of
the declarant upon the declarant’s death.
_____________________________________
Witness
_____________________________________
Witness
STATE OF TENNESSEE
COUNTY OF_____________________
Subscribed, sworn to and acknowledged before me by _________________________, the declarant, and subscribed and
sworn to before me by____________________ and____________________ , witnesses, this _______day of_____________, 20____.
__________________________________________
Notary Public
My Commission Expires:____________________
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