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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary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

_______________________________________
Signature

State of _______________
_________ County

We, the Declarant and the witnesses, being duly sworn each declare to the notary public or justice of the peace or other official signing below as follows:
1. The Declarant signed the instrument as a free and voluntary act for the purposes expressed, or expressly directed another to sign for him.
2. Each witness signed at the request of the Declarant, in his presence, and in the presence of the other witness.
3. To the best of my knowledge at the time of the signing the Declarant was at least 18 years of age, and was of sane mind and under no constraint or undue influence.

______________________________________________
Declarant

________________________________________________
Witness

________________________________________________
Witness

Sworn to and signed before me by ____________ Declarant, and ___________________________ witnesses on _____________________, 20____.

___________________________________________________
Signature

Official Capacity: _____________________
Statutory Declaration in Conformance with New Hampshire Terminal Care Document Law, N.H. R.S. 137-H: 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 New Hampshire. 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 artificially prolonged under the circumstances set forth below and declare that:

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 is my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures are used and if 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, food or fluids or the performance of any medical procedures deemed necessary to 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 have the emotionally and mental capacity 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 Arizona Medical Treatment Decision Act, AZ. REV. STAT. 36-3202
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 Arizona. 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.