SAMPLE LIVING WILL
Declaration made this _____ day of _____________, 20_____. I, __________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am both mentally and physically incapacitated _____ and I have a terminal condition initial or _____ and I have an end stage condition initial or _____ and I am in a persistent vegetative state initial and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the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 or to alleviate pain. It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal. In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life prolonging procedures, I wish to designate as my surrogate to carry out the provisions of this declaration. Name__________________________________________________________________ Address________________________________________________________________ __________________________________________________ Zip Code_____________ Phone:__________________________________________________________________ I understand the full importance of this declaration, and I am emotionally and mentally compete to make this declaration. Additional Instructions (optional) ____________________________________________ _______________________________________________________________________ _______________________________________________________________________ Declarant's Signature:_____________________________ Date Signed:______________ One of the two witnesses must not be related to the Declarant Witness:_____________________________Witness_____________________________ Address:_____________________________ Address____________________________ ______________________ Zip Code______ ____________________ Zip Code______ Phone______________________________ Phone_______________________________ Notary