Living Will

LIVING WILL DECLARATION

I, [Declarant], ("Declarant" herein), being of sound mind, and after careful

consideration and thought, freely and intentionally make this revocable declaration

to state that if I should become unable to make and communicate my own decisions on

life sustaining or life support procedures, then my dying shall not be delayed,

prolonged or extended artificially by medical science or life sustaining medical

procedures, all according to the choices and decisions I have made and which are

stated here in my Living Will.

It is my intent, hope and request that my instructions be honored and carried out by

my physicians, family and friends, as my legal right.

If I am unable to make and communicate my own decisions regarding the use of medical

life sustaining or life support systems and/or procedures, and if I have a sickness,

illness, disease, injury or condition which has been diagnosed by two (2) licensed

medical doctors or physicians who have personally examined me, (or more than two (2)

if required by applicable law), one of whom shall be my attending physician, as being

either (1) terminal or incurable certified to be terminal, or (2) a condition from which

there is no reasonable hope of my recovery to a meaningful quality of life, which may

reasonably be referred to as hopeless, although not necessarily "terminal" in the medical

sense, or (3) has rendered me in a persistent vegetative state, or (4) a condition of

extreme mental deterioration, or (5) permanently unconscious, then in the absence of my

revoking this Living Will, all medical life sustaining or life support systems and

procedures shall be withdrawn, unless I state otherwise in the following provisions.

Unless otherwise provided in this Living Will, nothing herein shall prohibit the

administering of pain relieving drugs to me, or any other types of care purely for my

comfort, even though such drugs or treatment may shorten my life, or be habit forming, or

have other adverse side effects.

[Pregnancy]

I am also stating the following additional instructions so that my Living Will is as clear as possible:

[Resuscitation (CPR)]

[Intravenous and Tube Feeding]

[Life Sustaining Surgery]

[New Medical Developments]

[Home or Hospital]

In the event that any terms or provisions of my Living Will are not enforceable or are not

valid under the laws of the state of my residence, or the laws of the state where I may be

located at the time, then all other provisions which are enforceable or valid shall remain in

full force and effect, and all terms and provisions herein are severable.

IN WITNESS WHEREOF, I have read and understand this Living Will, and I am freely and

voluntarily signing it on this ____________________ in the presence of witnesses.

Signed: _____________________________

[Declarant]

Street Address: _____________________________

County: _____________________________

City and State: _____________________________

WITNESSES

We, the undersigned witnesses, certify by our signatures below, that we are adult (at least 18 years old),

mentally competent persons; that we are not related to the Declarant by blood, marriage, or adoption;

that we do not stand to inherit anything from the Declarant by any means, including will, trust, operation

of law or the laws of intestate succession, or by beneficiary designation, nor do we stand to benefit in

any way from the death of the Declarant; that we are not directly responsible for the health or medical

care, or general welfare of the Declarant; that neither of us signed the Declarant's signature on this

document; and that the Declarant is known to us.

We hereby further certify that the Declarant is over the age of 18; that the Declarant signed this

document freely and voluntarily, not under any duress or coercion; and that we were both present together,

and in the presence of the Declarant to witness the signing of this Living Will on this _____________________.

Witness signature: _______________________________

Residing at: _______________________________

_______________________________

Witness signature: _______________________________

Residing at: _______________________________

______________________________

Notary Acknowledgment

State of _______________________ )

County of _____________________ )

This instrument was acknowledged before me on this _____________________ by [Declarant], the Declarant

herein, on oath stating that the Declarant is over the age of 18, has fully read and understands the above

and foregoing Living Will, and that the Declarant's signing and execution of same is voluntary, without

coercion, and is intentional.

____________________________

Notary Public

My commission or appointment expires: _______________

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