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    Missouri Living Will

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    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: ________________


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