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 Living Will Form One


of __________________________________

Declaration made this the _____ day of ____________, 20__.

I, _________________________, am at least eighteen (18) years of age and am of sound and disposing mind, willfully and voluntarily and do hereby make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below.

I further declare:

If, at any time I have an incurable injury, disease or illness certified in writing to be a terminal condition by my attending physician, and my attending physician has determined that my death will occur within a short period of time, and the use of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the provision of appropriate nutrition and hydration and the administration of medication and the performance of any medical procedure necessary to provide me with comfort, care, or to alleviate pain.

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


I hereby state that I understand the full import of this declaration.







Subscribed and sworn before me this the _____ day of ____________, 20__.

Witness my hand and seal.

_____________________________________ My commission expires:

Notary public

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