Living Will Declaration

LIVING WILL OF

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I, ________________________________, a resident of the City of ___________________, ________________ County, State of _____________, being of sound and disposing mind, memory and understanding, do hereby willfully and voluntarily make, publish and declare this to be my LIVING WILL, making known my desire that my life shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

l. This instrument is directed to my family, my physician(s), my attorney, my clergyman, any medical facility in whose care I happen to be, and to any individual who may become responsible for my health, welfare or affairs.

2. Death is as much a reality as birth, growth, maturity and old age. It is the one certainty of life. Let this statement stand as an expression of my wishes now that I am still of sound mind, for the time when I may no longer take part in decisions for my own future.

3. If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death is imminent, where the application of life-prolonging procedures and "heroic measures" would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally. I do not fear death itself as much as the indignities of deterioration, dependence and hopeless pain. I therefore ask that medication be mercifully administered to me and that any medical procedures be performed on me which are deemed necessary to provide me with comfort, care or to alleviate pain.

4. In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences for such refusal.

5. In the event that I am diagnosed as comatose, incompetent, or otherwise mentally or physically incapable of communication, I appoint __________________________________ to make binding decisions concerning my medical treatment.

6. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy.

7. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. I hope you, who care for me, will feel morally bound to follow its mandate. I recognize that this appears to place a heavy responsibility upon you, but it is with the intention of relieving you of such responsibility and of placing it upon myself, in accordance with my strong convictions, that this statement is made.

IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my seal at _______________, _______________, this _______ day of _________________, 20______, in the presence of the subscribing witnesses whom I have requested to become attesting witnesses hereto.



___________________________
Declarant

STATEMENT OF WITNESSES

The declarant is known to me and I believe him/her to be of sound mind.



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Witness #1 Signature

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Witness #1 Printed Name

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Address
 

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Witness #2 Signature

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Witness #2 Printed Name

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_____________________________________
Address
 

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

Subscribed and acknowledged, before me by ___________________________, and subscribed and sworn to before the witnesses, ___________________________ and ___________________________ on the _______day of ____________________, 20______.




____________________________                 (SEAL) 
NOTARY PUBLIC

State of ___________________

My Commission Expires: ____________________________



Copies of this instrument have been given to:

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Receipt and acknowledgment date:

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