Advance Directive For A Natural Death Form ("Living Will") (Page 3 of 5) in pdf

If I have an Available Health Care Agent

If I have appointed a health care agent by executing a health care power of attorney or similar

instrument, and that health care agent is acting and available and gives instructions that differ

from this Advance Directive, then I direct that:

Follow Advance Directive: This Advance Directive will override

(Initial)

instructions my health care agent gives about prolonging my life.

Follow Health Care Agent: My health care agent has authority to

(Initial)

override this Advance Directive.

NOTE: DO NOT INITIAL BOTH BLOCKS. IF YOU DO NOT INITIAL EITHER BOX, THEN

YOUR HEALTH CARE PROVIDERS WILL FOLLOW THIS ADVANCE DIRECTIVE AND

IGNORE THE INSTRUCTIONS OF YOUR HEALTH CARE AGENT ABOUT PROLONGING

YOUR LIFE.

My Health Care Providers May Rely on this Directive

My health care providers shall not be liable to me or to my family, my estate, my heirs, or my

personal representative for following the instructions I give in this instrument. Following my

directions shall not be considered suicide, or the cause of my death, or malpractice or

unprofessional conduct. If I have revoked this instrument but my health care providers do not

know that I have done so, and they follow the instructions in this instrument in good faith, they

shall be entitled to the same protections to which they would have been entitled if the instrument

had not been revoked.

I Want this Directive to be Effective Anywhere

I intend that this Advance Directive be followed by any health care provider in any place.

I have the Right to Revoke this Direction

I understand that at any time I may revoke this Advance Directive in a writing I sign or by

communicating in any clear and consistent manner my intent to revoke it to my attending

physician. I understand that if I revoke this instrument I should try to destroy all copies of it.

This the ____ day of _____________, _______.

Signature of

Declarant____________________________________________

Type/print name ______________________________________

I hereby state that the declarant, ________________________, being of sound mind, signed (or directed

another to sign on declarant's behalf) the foregoing Advance Directive for a Natural Death in my

presence, and that I am not related to the declarant by blood or marriage, and I would not be entitled to

any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir

Advance Directive For A Natural Death Form ("Living Will") Page 3