LIVING WILL

Living will made this _________________ day of ___________. I _______________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be prolonged under the circumstances set forth below, and do declare:
1. If at any time I should have a terminal condition as defined and established in accordance with the procedures set forth in paragraph 10 of Code Section 31-32-2 of the Official Code of Georgia, I direct that the application of life-sustaining procedures to my body be withheld or withdrawn and that I be permitted to die;
2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this living will 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. I understand that I may revoke this living will at any time;
4. I understand the full import of this directive and I am emotionally and mentally competent to make this living will; and
5. If I am female and I have been diagnosed as pregnant, this living will shall have no force or effect during the course of my pregnancy.

Signed _________________________________________
_________________________

City of residence: _______________
County of residence: _____________
State of residence: ______________

I hereby witness this living will and attest that:
1. The Declarant is personally known to me and I believe the Declarant to be at least 18 years of age and of sound mind;
2. I am at least 18 years of age;
3. To the best of my knowledge, at the time of the execution of this living will, I:
A) Am not related to the Declarant by blood or marriage;
B) Would not be entitled to any portion of the Declarant’s estate by any will or by operation of law under the rules of descent and distribution of this state;
C) Am not the attending physician of Declarant or an employee of the hospital or skilled nursing facility in which the Declarant is a patient;
D) Am not directly financially responsible for the Declarant’s medical care; and
E) Have no present claim against any portion of the estate of the Declarant;
4. Declarant has signed this document in my presence as above instructed, on the date above first shown.

Witness:

_____________________________________________________

Address:

Witness:
____________________________________________________
Address:

Living Will as Provided by Georgia Code, Section 31-32-3
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 Georgia. 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 OF ___________________

I, ____________, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death is imminent, and where the application 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 administration of medications 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 from such refusal.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. In acknowledgment whereof, I do hereinafter affix my signature on this the ___________ day of ______________ 20_____.

_____________________________________________________________
Declarant: ________________
Residing at : _____________
___________________________

We, the subscribing witnesses hereto, are personally acquainted with and subscribe our names hereto at the request of the Declarant, an adult, whom we believe to be of sound mind, fully aware of the action taken herein and its possible consequence. We, the undersigned witnesses, further declare that we are not related to the Declarant by blood or marriage; that we are not entitled to any portion of the estate of the Declarant upon his decease under any will or codicil thereto presently existing or by operation of law then existing; that we are not the attending physician, an employee of the attending physician or a health facility in which the Declarant is a patient; and that we are not a person who, at the present time, has a claim against any portion of the estate of the Declarant upon his death.

Witness: ______________________________________________

Witness: _______________________________________________

Subscribed, sworn to and acknowledged before me by ____________, the Declarant, and subscribed to before me by __________________________ and ________________________, witnesses, this _______ day of ___________________________ 20___.

_______________________________________________________________
Notary Public

Living Will as Provided by Tennessee Code 32-11-105
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 Tennessee. 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.