Go to Public Legal Home
  • Forms
    • Legal Forms Home
    • Business
    • Buying & Selling
    • Borrowing & Lending
    • Business Ventures
    • Credit & Collection
    • Employment
    • Leases & Real Estate
    • Protection of Rights
    • Transfers & Assigns
    • Personal
    • Last Wills & Estates
    • Marital & Family
    • Name Change
    • Power of Attorney
    • Health Care
  • Profession
    • 350 Largest Law Firms
    • Legal Salaries
    • CLE
    • Lawyers & Firms
    • Legal Associations
    • Legal Experts
    • Legal Forms Sources
    • Business Entity Forms
  • Academics
    • Law School Rankings
    • Law School Profiles
    • Law School Salaries
    • Law School Tuition
    • Law School Outlines
    • External, 3rd Party
    • Rankings Sources
    • Law Journals
    • Law Students
    • Pre-Law
  • Research
    • U.S. State Gov't
    • U.S. Federal Gov't
    • Legal Indices
    • Statutes & Codes
  • About
    • About Us
    • Contact Us
    • Testimonials
    • Terms of Use
    • Privacy Policy
  • Forms
  • Firms
  • Schools
    1. you are here:
    2. forms menu
    3. health care
    4. kansas living will
    1. you are here:
    2. forms menu
    3. health care
    4. kansas living will declaration
    1. you are here:
    2. forms menu
    3. health care
    4. kansas living will declaration

    Kansas Living Will Declaration

    Instant Download - Only $9.99

    • Professional MS Word & PDF formatting Microsoft Word Adobe PDF
    • Fully editable & reusable
    • Lifetime updates
    • Accuracy guarantee

    KANSAS LIVING WILL DECLARATION

    Note to Declarant:  Any adult person may execute a declaration directing the withholding or withdrawal of life-sustaining procedures in a terminal condition. A declaration made pursuant to Kansas Statute No. 65-28,103 must be: (1) in writing; (2) signed by the person making the declaration, or by another person in the declarant's presence and by the declarant's expressed direction; (3) dated; and (4) (A) signed in the presence of two or more witnesses at least 18 years of age neither of whom shall be the person who signed the declaration on behalf of and at the direction of the person making the declaration, related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession of this state or under any will of the declarant or codicil thereto, or directly financially responsible for declarant's medical care; or (B) acknowledged before a notary public. The declaration of a qualified patient diagnosed as pregnant by the attending physician shall have no effect during the course of the qualified patient's pregnancy.

    It shall be the responsibility of declarant to provide for notification to the declarant's attending physician of the existence of the declaration. An attending physician who is so notified shall make the declaration, or a copy of the declaration, a part of the declarant's medical records.

    The declaration shall be substantially in the following form, but in addition may include other specific directions. Should any of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which can be given effect without the invalid direction, and to this end the directions in the declaration are severable.

    DECLARATION

    Declaration made this ______ day of _____________________ (month, year).

    I, ____________________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:

     

    If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures 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 with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care.

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

     

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


    __________________________________________


    Signature of Person Making Declaration (Declarant)

    __________________________________________


    (Type or Print Name of Declarant)

    __________________________________________


    Street Address

    __________________________________________


    City                              State                   Zip Code

    The declarant has been personally known to me and I believe the declarant to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil thereto, or directly financially responsible for declarant's medical care.

    __________________________________________           __________________________________________


    Signature of 1st Witness                                                  Signature of 2nd Witness


     


    __________________________________________           __________________________________________


    (Type or Print Name of Witness)                                      (Type or Print Name of Witness)

     

    __________________________________________           __________________________________________


    Street Address                                                              Street Address

    __________________________________________           __________________________________________


    City                              State                   Zip Code        City                              State                   Zip Code


     

    (OR)

    STATE OF ______________________     ) 
                                                                ) ss.
    COUNTY OF ____________________     )

    This instrument was acknowledged before me on ________________________ (date) by __________________________________________ (name of person).



     

    __________________________________________                       (Seal, if any)


    (Signature of notary public)

     

    My appointment expires: ________________________


    Copies Delivered To:

     


    __________________________________________

    __________________________________________



    __________________________________________


    Other Forms You May Need

    • Kansas General Durable Power of Attorney for Property & Finances (Upon Disability)
    • Kansas General Durable Power of Attorney for Property & Finances (Immediate)
    • Kansas Durable Power of Attorney for Health Care Decisions

    Instant Download - Only $9.99

    • Professional MS Word & PDF formatting Microsoft Word Adobe PDF
    • Fully editable & reusable
    • Lifetime updates
    • Accuracy guarantee
    "Are these forms valid in my state?" At ILRG, we are committed to delivering top quality legal forms that are valid in all states. We will pay $50 to anyone who brings to our attention any form on our site that is not compliant with U.S. state law. See the terms and conditions for this offer for further information. ILRG guarantees your complete satisfaction with your purchase. If you are not 100 percent satisfied after purchasing from us, contact us for a full refund.

    No Ads, No Affiliates, No Subscription Plans, No Hidden Fees, No Sharing Your Data. PublicLegal is a socially motivated website that provides information about the law while respecting your rights and privacy. View our privacy policy.

    Legal Forms

    Business
    Buying & Selling
    Borrowing & Lending
    Business Ventures
    Credit & Collection
    Employment
    Leases & Real Estate
    Protection of Rights 
    Transfers & Assigns

    Personal
    Last Wills & Estates
    Marital & Family
    Name Change
    Power of Attorney
    Health Care

    Legal Profession

    350 Largest Law Firms
    Legal Salaries
    CLE
    Lawyers & Firms
    Legal Associations
    Legal Experts
    Legal Forms Sources
    Business Entity Forms

    Legal Academics

    Law School Rankings
    Law School Profiles
    Law School Salaries
    Law School Tuition
    Law School Outlines

    External, 3rd Party
    Rankings Sources
    Law Journals
    Law Students
    Pre-Law

    Legal Research

    U.S. State Gov't
    U.S. Federal Gov't
    Legal Indices
    Statutes & Codes



    About

    About Us
    Contact Us
    Testimonials
    Terms of Use
    Privacy Policy

    © 1995-2025 Internet Legal Research Group

    An operating division of PublicLegal LLC

    Reproduction in whole or in part without permission is prohibited.


    Truste seal 4b8271a7147141530b4450016f74d728419e6cea808360acdf2c25ce1ab6cf96