Living Will Declaration printable pdf download

SA034

Form A

LIVING WILL DECLARATION

THIS DECLARATION is made this______day of ________________________(month, year).

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 physician 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would only prolong the dying process be withheld or withdrawn, and that I be permitted to die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 by my attending physician to provide me with comfort

care.

In the absence of my ability to give direction 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.

Signed: ___________________________________

City, County and State of Residence:____________________________________

____________________________________

The declarant is personally known to me and I believe him or her to be of sound mind. I saw the

declarant sign the declaration in my presence (or the declarant acknowledged in my presence that

he or she had signed the declaration) and I signed the declaration as a witness in the presence of

the declarant. I did not sign the declarant’s signature above for or at the direction of the

declarant. At the date of this instrument, I am not entitled to any portion of the estate of the

declarant according to the laws of interstate succession or, to the best of my knowledge and

belief, under any will of declarant or other instrument taking effect at declarant’s death, or

directly financially responsible for declarant’s medical care.

Witness: _______________________________________

Living Will Declaration