Advance Directive For A Natural Death Form ("Living Will") (Page 4 of 5) in pdf

Advance Directive For A Natural Death Form ("Living Will") Page 4

under the Intestate Succession Act, if the declarant died on this date without a will. I also state that I am

not the declarant's attending physician, nor a licensed health care provider who is (1) an employee of the

declarant's attending physician, (2) nor an employee of the health facility in which the declarant is a

patient, or (3) an employee of a nursing home or any adult care home where the declarant resides. I

further state that I do not have any claim against the declarant or the estate of the declarant.

Date:

___________________________

Witness:

___________________________

Date:

___________________________

Witness:

___________________________

______________ COUNTY, ____________________ STATE

Sworn to (or affirmed) and subscribed before me this day by ___________________________________

(type/print name of declarant)

____________________________________

(type/print name of witness)

____________________________________

(type/print name of witness)

Date _____________________

______________________________________

Signature of Notary Public

(Official Seal)

___________________________, Notary Public

Printed or typed name

My commission expires: __________________

Advance Directive For A Natural Death Form ("Living Will") Page 4