Fillable Living Will Declaration printable pdf download

Living Will Declaration

I, __________________________________, do not want a living will.

I, __________________________________, do want a living will.

If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my

desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am

unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw

procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain.

I ( ) do

I ( ) do not desire that nutrition or hydration (food and water) be provided by gastric tube or intravenously

if necessary.

Notwithstanding the other provisions of this declaration, if I have donated an organ under this declaration or by

another method, and if I am in a hospital when a “do not resuscitate” order is to be implemented for me, I do not want the

“do not resuscitate” order to take effect until the donated organ can be evaluated to determine if the organ is suitable for

donation.

Other directions: ____________________________________________________________________________

________________________________________________________________________________________________

OPTIONAL: In the event of my death, I donate the following part(s) of my body for the purposes identified in AS

13.50.020:

____ any needed tissue or organ.

____ only the following tissues and/or organs:

Tissues: ___ eyes/corneas; ___ bone and connective tissue; ___ skin grafts; ___ heart for valves; ___ additional

research tissue.

Organs: ___ kidneys; ___ heart; ___ lungs; ___ liver; ___ pancreas.

Limitations or special wishes: __________________________________________________________________

THIS DECLARATION MUST SIGNED BY THE DECLARANT. IF THE DECLARANT CANNOT SIGN AND DIRECTS

THAT ANOTHER PERSON SIGN ON THE DECLARANT’S BEHALF, THE SIGNATURE MUST EITHER BE

WITNESSED BY TWO PERSONS OR ACKNOWLEDGED BY A PERSON QUALIFIED TO TAKE

ACKNOWLEDGMENTS UNDER AS 09.63.010.

Date: _________________

Declarant’s Signature: ____________________________________________________

Place signed: _______________________________________, Alaska.

The foregoing instrument was acknowledged before me this ____ day of ___________________________, 20 _____, by

__________________________________________________________________________________________

Signature of Person Taking Acknowledgment and Title or Rank

The declarant is known to me and voluntarily directed another to sign this document in my presence.

Signature and Address of Witness:

___________________________________________________________________

Signature and Address of Witness:

___________________________________________________________________

Use translation clause on back if necessary. A physician or health care provider may presume, in the absence of

actual notice to the contrary, that this declaration complies with A.S. 18.12.010 and is valid.

Living Will Declaration