LIVING WILL FORM or HEALTH CARE DIRECTIVE TO PHYSICIANS
Directive made and executed by _________[name],
of _________[address], _________[state], on _________[date].
I, _________, being of sound mind, willfully and voluntarily
make known my desire that my life shall not be artificially
prolonged under the following circumstances:
1. If at any time I should have an incurable terminal condition
caused by injury or illness, for which the application of
life-sustaining procedures would only serve to artificially
prolong the moment of my death, I direct that such procedures
be withheld or withdrawn, and that I be permitted to die naturally.
2. If at any time I am determined to be permanently unconscious,
i.e. that I am in a permanent coma or vegetative state, I
direct that I be allowed to die and not be kept alive through
life support systems.
3. In the absence of my ability to actively take part in decisions
for my own life and give directions regarding the use of such
life-sustaining procedures, it is my wish that this directive
stand as a statement of my wishes and shall be honored by
my family and physicians.
4. This directive shall have no force or effect _________
years from the date filled in above.
5. I understand the full meaning of this directive, and I
am emotionally and mentally competent to make this directive.
6. I understand that I may revoke this directive at any time.
[Signature]
Witnesses Statement
On _________[date], this document was signed in our presence,
by _________[name], who appeared to be of sound mind and able
to understand the medical instructions set forth in the above
directive, and their consequences.
We now sign our names as witnesses in the author’s presence
and at the author’s request, and in the presence of each other.
residing at
[Signature] [Street, city, state]
residing at
[Signature] [Street, city, state]
residing at
[Signature] [Street, city, state]
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