Statutory Living Will Declaration Form - Kansas printable pdf download

STATUTORY LIVING WILL DECLARATION

Declaration made this _____ day of __________________, 20___.

I, _________________________________, date of birth ________________, of ________________ (city),

________________ (county), and _______________________ (state), being of sound mind, willfully and voluntarily

make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, subject

to later revocation, and 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 only serve to 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withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any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 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 agent, 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.

I understand the full significance of this declaration, and I am emotionally and mentally competent to make this

declaration.



I do not wish to make additional instructions.



My additional instructions are listed on the reverse side (or page 2) of this form.

Signature of Declarant _________________________________________________________________

(May be signed by another person in the declarant’s presence and by the declarant’s expressed direction.)

This document must be signed in the presence of two witnesses OR acknowledged by a notary public.

By signing below, I certify the following: The declarant has been personally known to me and I believe the declarant to

be of sound mind and 18 years or older. The declarant voluntarily signed this document in my presence. I did not sign

the declarant’s signature above for or at the direction of the declarant. I am not related to the declarant by blood or

marriage, am not entitled to any portion of the estate of the declarant either as a legal heir or under any Will of declarant

or any addition thereto, and am not directly financially responsible for declarant’s medical care.

(1)

Witnesses – two individuals of lawful age who are not the agent; not related to the principal by blood, marriage,

or adoption; not entitled to any portion of the principal’s estate; and not financially responsible for principal’s health care.

Witness __________________________________

Address __________________________________

(2)

STATE OF KANSAS

)

) ss:

COUNTY OF ____________________ )

This instrument was acknowledged before me on this _____ day of ___________________, 20___.

Signature of Notary Public

_____________________________________

My appointment expires:

_____________________________________

00003720S

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Discuss this document with your physician(s), family members, designated agent(s), and clergy, and provide them with a signed copy or photocopy.

Statutory Living Will Declaration Form - Kansas

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