I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct that my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.

Signed this ____________________ day of _______________

________________________________________________________________

Signature: __________________
City of residence: __________
County of residence: ________
State of residence: _________

The Declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence.

________________________________________________________________

Witness
Address:

________________________________________________________________

Witness
Address:

Declaration in Conformance with Missouri Statutes 459.015
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Missouri. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________. I, __________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, do hereby declare:
1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally,
2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
3. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy.
4. I have been diagnosed and notified at least 14 days ago as having a terminal condition by __________________, M.D. whose address is ___________, __________.

I understand that if I have not filed in the physicians name and address, it shall be presumed that I did not have a terminal condition when I made out this directive.
5. This directive shall have no force and effect five years from the date filled in above.
6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

_________________________________________________

The Declarant has been personally known to me and I believe him or her to be of sound mind.

Witness __________________________________________________

Witness __________________________________________________

Directive to Physicians as Provided by the California Health and Safety Code: Section 7187
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in California. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to be. To any individual who may become responsible for my health, welfare or affairs.

Death is as much a reality as birth, growth, maturity and old age — it is the one certainty of life. If the time comes when I, ________________, can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes while I am still of sound mind.

If the situation should arise in which I am in terminal state and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I do, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life.

This statement 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 will is addressed will regard themselves as morally bound by these provisions. If it is permissible under the laws of the jurisdiction in which I may be hospitalized I direct that the physicians supervising my care upon a terminal diagnosis to discontinue hydration (water) should the continuation of hydration be judged to result in unduly prolonging a natural death.

If it is permissible under the laws of the jurisdiction in which I may be hospitalized I direct that the physicians supervising my care upon a terminal diagnosis to discontinue feeding should the continuation of hydration be judged to result in unduly prolonging a natural death.

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 relative 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:

_______________________________________________________________

City of residence: _______________
County of residence: _____________
State of residence: ______________
Social Security Number: __________

Date: _________________

________________________________________________________________
Witness

________________________________________________________________
Witness

STATE OF ________________________
COUNTY OF _______________________

This day personally appeared before me, the undersigned authority, a Notary Public in and for ______________ County, ___________________________State, ______________________________ _______________________________(Witnesses) who, being first being duly sworn, say that they are the subscribing witnesses to the declaration of ________________, 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 ________________, Declarant, and in his presence, and that ________________ at the time the declaration was executed, in the opinion of the affiants, of sound mind and memory, and over the age of eighteen years.
Taken, subscribed and sworn to before me by _________________ (witness) and ____________________________ (witness) this _______ day of ____________________________, 20_____.

My commission expires: __________________

___________________________________
Notary Public

Living Will
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in many states. It is a general format for those states without specific ones, though it will generally be enforced if done and properly witnessed, in most states. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION OF ______________________

This declaration is made this __________ day of __________ 20___________. I, _____________________________, being of sound mind, willfully and voluntarily make known my desires that my moment of death shall not be artificially postponed.

If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal condition by my attending physicians who has personally examined me, and has determined that my death is imminent except for death delaying procedures, I direct that such procedures which would serve only to prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide me with comfort care.

In the absence of my ability to give directions regarding the use of such death delaying procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

________________________________________

City of Residence: ________________
County of Residence: ______________
State of Residence: _______________

Date: __________________________________

Witness _________________________________________________

Witness _________________________________________________

Date: ___________________________________

Statutory Declaration in Conformance with Illinois Natural Death Act, IL. Stat. 110 ½ Paragraph 703
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Illinois. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

I, ________________, desire to make aware that after mature reflection, and, being aware of the right under the law to decline life- sustaining treatment, that I wish, should I ever be unable to make decisions for myself concerning my medical treatment that I receive life sustaining treatment even after a terminal diagnosis, even if the life prolonging treatment will delay the natural process of dying.

I have previously made a “living will” or other document expressing a desire contrary to that specified herein, and by this document I herewith revoke the same.

Dated: _________________________________________

________________________________________________
Declarant

________________________________________________
Witness & Address

________________________________________________
Witness & Address

________________________________________________
Witness & Address

City of residence: _______________
County of residence: _____________
State of residence: ______________
Social Security Number: __________

Date: _________________

________________________________________________________________
Witness

________________________________________________________________
Witness

STATE OF ________________________
COUNTY OF _______________________

This day personally appeared before me, the undersigned authority, a Notary Public in and for ______________ County, ___________________________State, ______________________________ _______________________________(Witnesses) who, being first being duly sworn, say that they are the subscribing witnesses to the declaration of ________________, 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 ________________, Declarant, and in his presence, and that ________________ at the time the declaration was executed, in the opinion of the affiants, of sound mind and memory, and over the age of eighteen years.
Taken, subscribed and sworn to before me by _________________ (witness) and ____________________________ (witness) this _______ day of ____________________________, 20_____.

My commission expires: __________________

Revocation of Previous Living Will and Medical Care Restrictions
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This review list is provided to inform you about this document in question and you in its preparation. Revocations are generally made because of a serious change in attitude. Therefore, you should be very careful to have your wishes implemented. Get three witnesses; have them notarized; get the documents in everyone’s hands that previously had one; and try to recover as many originals as you can, that you handed out previously, to avoid conflicting directions.

DIRECTIVE TO PHYSICIANS

Date __________________

I, _______________, being of sound mind, intentionally and voluntarily declare:
1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally,
2. It is my intention that this directive shall be honored by my family and attending physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
3. If I have been diagnosed as pregnant and that fact is known to my physician, this directive shall have no force or effect during the course of my pregnancy. I understand the full import of this directive and I am emotionally and mentally competent to execute it.

Signed _________________________________________________

STATE OF _______
COUNTY OF __________

Dated: _________________________

Then and there personally appeared the within named ________________________________ and __________________________, who, being duly sworn, depose and say: That they witnessed the execution of the within Directive to Physicians of the within named _______________, that said declarant subscribed said Directive to Physicians and declared the same to be his Directive to Physicians in their presence, that they thereafter subscribed the same as witnesses in the presence of said declarant and in the presence of each other and at the request of said declarant; that the said declarant at the time of the execution of said Directive
to Physicians appeared to them to be of full age and of sound mind and memory, and that they make this affidavit at the request of said declarant.

________________________________________
Witness
________________________________________
Witness

Subscribed to and sworn to before me this ________ day of _________, 20_____.

_____________________________________________
Notary Public

Directive to Physicians as Provided by Nevada Revised Statutes, Section 449.610
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Nevada. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION OF ________________________

Declaration made this __________ day of _____________ 20________. I ___________ willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:

If at any time I should have a terminal condition, and if my attending physician has determined that there can be no recovery from such condition and my death is imminent, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences for such refusal.

If I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

_______________________________________
_______________________________________
City of residence: _____________________
County of residence: ___________________
State of residence: ____________________

Date: ________________________

The Declarant has been personally known to me and I believe him or her to be of sound mind.

Witness: ___________________________________________

Witness: ___________________________________________

Date: ___________________________

Statutory Declaration in Conformance with Florida Life Prolonging Procedure Act, F.S. 765.05
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Florida. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

LIVING WILL DECLARATION OF ________________

Declaration made this __________ day of _________________ 20________.

I, _____________, being at least eighteen (18) years old and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare:

If at any time I should have an incurable and irreversible 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 in 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 deemed necessary to provide me with comfort care or to alleviate pain.

In the absence of my ability to give directions regarding the use of such life prolonging delaying procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of the refusal.

I understand the full import of this declaration.

________________________________________
City of Residence: ____________________
County of Residence: __________________
State of Residence: ___________________

Date: _________________

The Declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the Declarant’s signature above for or at the direction of the Declarant. I am not a parent, spouse, or child of the Declarant. I am not entitled to any part of the Declarant’s estate or directly financially responsible for Declarant’s medical care. I am competent and at least eighteen (18) years old.

Witness _________________________________________________

Witness _________________________________________________

Date: _______________________

Statutory Declaration in Conformance with Indiana Living Will and Life-Prolonging Procedures Act, Indiana Code 16-8-11-12
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Indiana. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

I, ________________, being of sound mind, desire that my life not be prolonged by extraordinary means if my condition is determined to be terminal and incurable. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means.

This the ______________ day of ___________________ 20___.

________________________________________________
SIGNATURE

I hereby state that the Declarant, ________________, being of sound mind signed the above declaration in my presence and that I am not related to the Declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the Declarant, under any existing will or codicil of the Declarant, or as an heir under the Interstate Succession Act if the Declarant died on this date without a will. I also state that I am not the Declarant’s attending physician or an employee of the Declarant’s attending physician or an employee of a health facility in which the Declarant is a patient or an employee of a nursing home or any group-care home where the Declarant resides. I further state that I do not now have any claim against the Declarant.

Witness

____________________________________________________________

Witness

____________________________________________________________

CERTIFICATE
I, _____________________________________________(state if Clerk of Superior Court or Deputy Clerk or Notary Public) for _________________________________ County, hereby certify that ________________, the Declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his Declaration Of A Desire for A Natural Death, and that he willingly and voluntarily made and executed it as his free act and deed for the purposes expressed in it, I further certify that __________________________________ and

__________________________ witnesses, appeared before me and swore that they witnessed ________________, Declarant, sign the attached declaration, believing him to be of a sound mind; and also swore that at the time they witnessed the declaration (i) they were not elated within the third degree to the Declarant or to the Declarant’s spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the Declarant upon the Declarant’s death under any will of the Declarant or codicil thereto then existing or under the Interstate Succession Act as it provides at that time, and (iii) they were not a physician attending the Declarant or an employee of an attending physician or an employee of a health facility in which the Declarant was a patient or an employee of a nursing home or any group-care home in which the Declarant resided, and (iv) they did not have a claim against the Declarant.

I further certify that I am satisfied as to the genuineness and due execution of the declaration. This the _________ of ______________, 20______.

________________________________________________

Title: ____________________________________
County of _____________

Declaration of a Desire for a Natural Death as Provided by North Carolina G.S. 90-321
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in North Carolina. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION

If I should have an incurable or irreversible condition that will cause my death within a reasonable short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain. It is my intention that this declaration shall be valid until revoked by me.

Signed this ___________________ day of ______________

________________________________________________________________
Signature: ______________
City of residence: __________________
County of residence: ________________
State of residence: _________________

The Declarant is known to me and voluntarily signed this document in my presence.

Witness:

_____________________________________________________________

Witness:

_____________________________________________________________

Declaration as Provided by Montana Stats. 50-9-104
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Montana. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.