Living Will Directive Page 10
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10COMMONWEALTH OF KENTUCKY)
................................... COUNTY)
Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18) years of age, or older,
and acknowledged that he voluntarily dated and signed this writing or directed it to be signed and dated as above.
Done this .... day of ........, 20___.
Notary Public:
___________________________
Date Commission Expires:
___________________________
Execution of this document restricts withholding and withdrawing of some medical procedures. Consult Kentucky Revised
Statutes or your attorney.
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