LIVING WILL OF (Insert name of declarant)
DECLARATION made on __________ by________ of___________
County, _______________, Social Security No.________________ .
I, ________________, being of sound mind, declare that if at any time I should suffer a terminal physical condition which causes me severe distress or unconsciousness, and my physician, with the concurrence of two (2) other physicians, believes that there is no expectation of my regaining consciousness or a state of health that is meaningful to me but for the use of life-sustaining mechanisms my death would be imminent, I desire that the mechanisms be withdrawn so that I may die naturally. I further declare that this Declaration should be honored by my family and my physician as the final expression of my desires concerning the manner in which I die.
WITNESS my signature, this the ____ day of __________ , 20__ .
Signature: ______________ Date:_______________
Name: _________________ Address:_____________
_________________Social Security #____________________
Next of Kin:_________________________________________
I hereby witness this Declaration and attest that:
1. I, personally know the Declarant and believe the Declarant to be of sound mind;
2. To the best of my knowledge, at the time of the execution of this Declaration, I:
(a) am not related to the Declarant by blood or marriage,
(b) do not have any claim on the estate of the Declarant,
(c) am not entitled to any portion of the Declarant’s estate by any will or by operation of law, and
(d) am not a physician attending the Declarant or a person employed by a physician attending the Declarant.
Social Security #__________ Social Security #_____________
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