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delaying procedures, I direct that such procedures which would serve only to prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary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
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 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.