Living will declaration
Living will declaration form
LIVING WILL DECLARATION
I, [Declarant], ("Declarant" herein), being of sound mind, and after careful
consideration and thought, freely and intentionally make this revocable declaration
to state that if I should become unable to make and communicate my own decisions on
life sustaining or life support procedures, then my dying shall not be delayed,
prolonged or extended artificially by medical science or life sustaining medical
procedures, all according to the choices and decisions I have made and which are
stated here in my Living Will.
It is my intent, hope and request that my instructions be honored and carried out by
my physicians, family and friends, as my legal right.
If I am unable to make and communicate my own decisions regarding the use of medical
life sustaining or life support systems and/or procedures, and if I have a sickness,
illness, disease, injury or condition which has been diagnosed by two (2) licensed
medical doctors or physicians who have personally examined me, (or more than two (2)
if required by applicable law), one of whom shall be my attending physician, as being
either (1) terminal or incurable certified to be terminal, or (2) a condition from which
there is no reasonable hope of my recovery to a meaningful quality of life, which may
reasonably be referred to as hopeless, although not necessarily "terminal" in the medical
sense, or (3) has rendered me in a persistent vegetative state, or (4) a condition of
extreme mental deterioration, or (5) permanently unconscious, then in the absence of my
revoking this Living Will, all medical life sustaining or life support systems and
procedures shall be withdrawn, unless I state otherwise in the following provisions.
Unless otherwise provided in this Living Will, nothing herein shall prohibit the
administering of pain relieving drugs to me, or any other types of care purely for my
comfort, even though such drugs or treatment may shorten my life, or be habit forming, or
have other adverse side effects.
[Pregnancy]
I am also stating the following additional instructions so that my Living Will is as clear as possible:
[Resuscitation (CPR)]
[Intravenous and Tube Feeding]
[Life Sustaining Surgery]
[New Medical Developments]
[Home or Hospital]
In the event that any terms or provisions of my Living Will are not enforceable or are not
valid under the laws of the state of my residence, or the laws of the state where I may be
located at the time, then all other provisions which are enforceable or valid shall remain in
full force and effect, and all terms and provisions herein are severable.
IN WITNESS WHEREOF, I have read and understand this Living Will, and I am freely and
voluntarily signing it on this ____________________ in the presence of witnesses.
Signed: _____________________________
[Declarant]
Street Address: _____________________________
County: _____________________________
City and State: _____________________________
WITNESSES
We, the undersigned witnesses, certify by our signatures below, that we are adult (at least 18 years old),
mentally competent persons; that we are not related to the Declarant by blood, marriage, or adoption;
that we do not stand to inherit anything from the Declarant by any means, including will, trust, operation
of law or the laws of intestate succession, or by beneficiary designation, nor do we stand to benefit in
any way from the death of the Declarant; that we are not directly responsible for the health or medical
care, or general welfare of the Declarant; that neither of us signed the Declarant's signature on this
document; and that the Declarant is known to us.
We hereby further certify that the Declarant is over the age of 18; that the Declarant signed this
document freely and voluntarily, not under any duress or coercion; and that we were both present together,
and in the presence of the Declarant to witness the signing of this Living Will on this _____________________.
Witness signature: _______________________________
Residing at: _______________________________
_______________________________
Witness signature: _______________________________
Residing at: _______________________________
______________________________
Notary Acknowledgment
State of _______________________ )
County of _____________________ )
This instrument was acknowledged before me on this _____________________ by [Declarant], the Declarant
herein, on oath stating that the Declarant is over the age of 18, has fully read and understands the above
and foregoing Living Will, and that the Declarant's signing and execution of same is voluntary, without
coercion, and is intentional.
____________________________
Notary Public
My commission or appointment expires: _______________
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