Fillable Living Will Declaration printable pdf download

Living Will Declaration

Declaration made this________day of___________________________________(Month, Year).

I,________________________________________, being of sound mind, willfully and voluntarily make known

my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby

declare:

If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two

physicians who have personally examined me, one of whom shall be my attending physician, and the physicians

have determined that my death will occur whether or not life-sustaining procedures are utilized and where the

application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that

such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration

of medication or the performance of any medical procedure deemed necessary to provide me with comfort care.

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my

intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal

right to refuse medical or surgical treatment and accept the consequences from such refusal.

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

declaration.

My additional instructions, if any, are listed on the reverse side.

Signed

____________________________________________________________________

(Declarant)

City, County and State of Residence

_____________________________________________

The declarant has been personally known to me and I believe the declarant to be of sound mind. I did not sign

the declarant's signature above for or at the direction of the declarant. I am 18 or older, not related to the

declarant by blood or marriage, not entitled to any portion of the estate of the declarant according to the laws of

intestate succession or under any will of the declarant or codicil thereto, and not directly financially responsible

for declarant's medical care.

________________________________________

Witness

________________________________________

Address

________________________________________

Witness

________________________________________

Address

Living Will Declaration