TESTAMENT

If the time comes when I am incapacitated to the point where I can no longer actively take part in decisions for my own life, and am unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes. I _________________ request that I be allowed to die and not be kept alive through life support system if my condition is deemed terminal. I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.

This request is made, after careful reflection, while I am of sound mind.

Signed ______________________________________________

Witness __________________________________________________

Witness __________________________________________________

Living Testament as Provided by Connecticut Statutes Section 19a-575
Review List

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 Connecticut. 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 ______________

If I should have an incurable or irreversible condition that will cause my death within a relatively 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 to alleviate pain.

I do [] do not [] desire that nutrition or hydration (food and water) be provided by gastric tube or intravenously if necessary.

Signed this______ day of _____________________, 20____.

Signature:

________________________________________________________________

Place of signing: _____________________

The Declarant is known to me and voluntarily signed or voluntarily directed another to sign this document in my presence.

Witness:

________________________________________________________________
Signature

Address:

________________________________________________________________
Signature

Address:

State of _________________________
__________________________________ Judicial District

The foregoing instrument was acknowledged before me this ______ day of _____________________, 20____ by ___________________.

_________________________________________
Signature of person taking acknowledgment

Declaration as Provided by Alaska Statutes, Section 18.12.010: Life Sustaining Declaration
Review List

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 Alaska. 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, ______________, being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:

If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life- sustaining procedures are utilized and where the application of life-sustaining 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 administration of medication or the performance of any medical procedure deemed necessary too provide me with comfort care.

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 from such refusal.

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. I did not sign the declarant’s signature above for or at the declaration of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil thereto, or directly financially responsible for declarant’s medical care.

Witness ______________________________________________

Witness ______________________________________________

Date: ___________________________________________
Statutory Declaration in Conformance with Alabama Natural Death Act, Al. Code 22-8A-4.
Review List

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 Alabama. 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.