Nebraska Living Will Declaration Form
ADVERTISEMENT
1Nebraska Living Will Declaration
If I, _________________________________________, the principal, should lapse into a persistent vegetative state or have an
incurable and irreversible condition, that, without the administration of life-sustaining treatment, will, in the
opinion of my attending physician, cause my death within a relatively short time AND I am no longer able to
make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Rights of the
Terminally Ill Act, to withhold or withdraw life-sustaining treatment that is not necessary for my comfort or to
alleviate pain.
You may list specific life-sustaining treatments you do not want such as cardiac resuscitation, mechanical
respiration (i.e breathing machine) and artificial feeding/ fluids by tube. Otherwise, your general statement,
above, will stand for your wishes.
I especially do not want:
________________________________________________________________________________________________________________________
You may want to add instructions or care you do want such as pain medication, preference to die at home, if
possible. ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Signature______________________________________
Date __________________
Address, City, State, Zip Code________________________________________________________________________________________
Declaration of Witnesses
THIS DOCUMENT MUST BE SIGNED BY TWO WITNESSES OR A NOTARY PUBLIC
We declare that the principal is personally known to us, that the principal signed or acknowledged his or her
signature on this Living Will Declaration in our presence, and that the principal appears to be of sound mind and
not under duress or undue influence, and that neither of us, nor the principal’s attending Physician, Nurse
Practitioner, or Physician’s Assistant is the person appointed as attorney-in-fact.
__________________________________
__________________________________
Witness Signature
Witness Signature
_________________________________________
_________________________________________
Print Name
Print Name
____________________________________________
____________________________________________
Address
Address
_____________________________________________________
_____________________________________________________
_________________
_________________
Date
Date
State of Nebraska
)
OR
)SS.
County of ____________________
)
On this _______ day of _________________ 20____, before me, __________________________________________________,
a notary public in and for _____________________________ County, ____________________________________________ voluntarily
signed this document in my presence.
Witness my hand and notarial seal at ________________________ in such county the day and year last written.
____________________________________________
Notary Signature
Seal
1 of 1
Updated 3/2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal