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LIVING WILL
(Florida Statutes 765-303)

Declaration made this _____ day of _______________________________________, 20_____, I, ___________________________________________________________________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am incapacitated and (initial as applicable)

________ I have a terminal condition

________ I have an end-stage condition

________ I am in a persistent vegetative state

and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that lifeprolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the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 or to alleviate pain.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide express and informed consent
regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to
designate, as my surrogate to carry out the provisions of this declaration:

Name: ________________________________________________________________________

Address: ______________________________________________________________________

______________________________________________________________________

Zip Code: ___________________

Phone: _____________________

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

Additional instructions (optional):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Name: ________________________________________________________________________

Signed: _______________________________________________________________________

Date: ______________________________

Witnesses:

1. Signature: __________________________________________________________________

Printed Name: ______________________________________________________________

Address: ___________________________________________________________________

2. Signature: __________________________________________________________________

Printed Name: ______________________________________________________________

Address: ___________________________________________________________________


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