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LIVING WILL AND DIRECTIVE TO MY PHYSICIANS

I ________________________________________, being of sound mind and memory,
and over the age of eighteen years, hereby declare this to be my living will and health
care directive to my treating physicians, my family, my physician, my lawyer, and my clergyman.
I want this living will and health care directive followed by the staff of any medical facility in whose
care I happen to be under and by any individual or family member who may become responsible
for my health, welfare or affairs. 

If the time comes when I, _____________________________________, can no longer take part
in decisions concerning my own health and medical treatment, let this living will and health care directive
stand as a firm expression of my wishes.

Each paragraph I have initialed below indicates my specific wishes regarding my health care:

1. _______ If I should at any time have an incurable condition caused by a disease or illness, or by an
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measures and procedures be  withheld or withdrawn and that I be permitted to die naturally.
I do, however, ask that medication be mercifully administered to me to alleviate suffering even
though this may shorten my remaining life.

2. _______  If it is permissible under the laws of the jurisdiction in which I may be hospitalized,
I direct that the physician(s) supervising my care, upon a terminal diagnosis, as described in
paragraph 1 above, discontinue hydration(water) should the continuation of hydration be judged
to result in the unduly prolonging of a natural death.  

3. _______  If it is permissible under the laws of the jurisdiction in which I may be hospitalized,
I direct that the physician(s) supervising my care, upon a terminal diagnosis, as described in
paragraph 1 above, discontinue feeding me or remove any feeding tubes from my body,
should the continuation of said feeding be judged to result in the unduly prolonging of a natural death.  

4. _______   I reserve the right to revoke this directive at any time.

5. _______   This living will and directive shall remain in force unless I revoke it.

This statement and living will is made after careful consideration and is in
accordance with my strong convictions and beliefs.  I want the wishes and directions
here expressed carried out to the extent permitted by law.  Insofar as they are not
legally enforceable, I hope that those to whom this living will is addressed will regard
themselves as morally bound by these provisions.

I herewith release any and all hospitals, physicians, and others both for myself and for
my estate from any and all liability for complying with this declaration, to the fullest
extent provided by law.

I herewith authorize my spouse, if any, or any family member who is related to me within the third degree
to effectuate my transfer from any hospital or other health care facility in which I may be receiving care should
that facility decline or refuse to effectuate the instructions given herein.  

Signed this ______ day of _________________, 2_____
______________________________________ (Declarant)
City: _____________________________(CITY IN WHICH DECLARANT RESIDES) 
County: __________________________ (COUNTY WHICH DECLARANT RESIDES) 
State: ____________________________(STATE IN WHICH DECLARANT RESIDES) 
Social Security Number: _____-___-_____ (DECLARANT'S SOCIAL SECURITY NUMBER)

WITNESS AFFIDAVIT

I am not related to (DECLARANT’S NAME) by blood or marriage, nor would
I be entitled to any portion of his or her's estate upon his/her death.  I am
not an attending physician of (DECLARANT’S NAME).  I am not an employee
of the attending physician, nor an employee of a health care facility in which
(DECLARANT’S NAME) may be a patient.  I am not a patient in a health
care facility in which (DECLARANT’S NAME) may be or is a patient.  I am
not a person who has any claim against or interest in any portion of the estate
of the declarant upon his/her death.

Witness #1                

Name: _______________________________________________________________

Signature: ____________________________________________________________ 

Address: _____________________________________________________________

Witness #2
Name: _______________________________________________________________

Signature: ____________________________________________________________ 

Address: _____________________________________________________________ 


                                             
NOTARY AFFIDAVIT 

 

STATE OF _______________________ COUNTY OF ________________________

This day personally appeared before me, the undersigned authority,
a Notary Public in and for ___________________ County, __________________State,

who, being first being duly sworn, say that they are the subscribing witnesses to
the declaration of (NAME OF DECLARANT), the declarant, signed, sealed and
published and declared the same as and for his declaration, in the presence of
both these affiants; and that these affiants, at the request of said declarant, in
the presence of each other, and in the presence of said declarant, all present at
the same time, signed their names as attesting witnesses to said declaration. 

            Affiants further say that this affidavit is made at the request of

____________________________________, the declarant, and that in our presence

____________________________________, the declarant executed this Living Will
and Healthcare Directive and in the opinion of the affiants, was of sound mind and memory,
and over the age of eighteen years.

Subscribed, and sworn this ______day of ____________, 20__.

Notary Public __________________________________

My commission expires: __________________
                                                    (SEAL)