MISSOURI LIVING WILL

 

DECLARATION

 

I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.

 

Signed this _____ day of ______________, 20_____.

 

 

________________________________            ________________________________

Printed Name of Declarant                              Signature of Declarant

 

Address:     ____________________________________________

____________________________________________

 

  

WITNESSETH

 

The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence.

 

Witness #1:                                                  Witness #2:

 

 

________________________________            ________________________________
Signature                                                      Signature

 

________________________________            ________________________________
Printed Name                                                Printed Name

                                                                                                                       

________________________________            ________________________________
Address, Line 1                                             Address, Line 1

 

________________________________            ________________________________
Address, Line 2                                             Address, Line 2

 

 

 

 

REVOCATION PROVISION

 

 

I hereby revoke the above declaration.

 

 

________________________________            ________________________________

Printed Name of Declarant                              Signature of Declarant

 

 

Date: ________________

Other Forms You May Need

• Missouri General Durable Power of Attorney for Property & Finances (Upon Disability)
• Missouri General Durable Power of Attorney for Property & Finances (Immediate)