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LIVING WILL
I, __________ , of __________ , being of sound mind, do hereby willfully and voluntarily
make known my desire that my life not be prolonged under any of the following conditions,
and do hereby further declare:
If I should, at any time, have an incurable condition caused by any disease or
illness, or by any accident or injury, and be determined by any two or more physicians
to be in a terminal condition whereby the use of "heroic measures"or the
application of life-sustaining procedures would only serve to delay the moment of my
death, and where my attending physician has determined that my death is imminent whether
or not such "heroic measures" or life-sustaining measures are employed, I
direct that such measures and procedures be withheld or withdrawn and that I be
permitted to die naturally. In the event of my inability to give directions regarding the application of
life-sustaining procedures or the use of "heroic measures", it is my
intention that this directive shall be honored by my family and physicians as my final
expression of my right to refuse medical and surgical treatment, and my acceptance of
the consequences of such refusal. I am mentally, emotionally and legally competent to make this directive and I
fully understand its import. I reserve the right to revoke this directive at any time.
This directive shall remain in force until revoked.
IN WITNESS WHEREOF, I have hereto set my hand and seal this ________ day of ________ ,
20 ________ .
Signed: __________
Declaration of Witnesses
The declarant is personally known to me and I believe him to be of sound mind and
emotionally and legally competent to make the herein contined Directive to Physicians.
I am not related to the declarant by blood or marriage, nor would I be entitled to any
portion of the declarant's estate upon his decease, nor am I an attending physician of
the declarant, nor an employee of the attending physician, nor an employee of a health
care facility in which the declarant is a patient, nor a patient in a health care
facility in which the declarant is a patient, nor am I a person who has any claim
against any portion of the estate of the declarant upon his death.
Signed: _____________
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