At your Own Risk
LIVING WILL OF
I, __________________________________________________, a resident
of the City of ___________________, ________________ County, State
of _____________, being of sound and disposing mind, memory and
understanding, do hereby willfully and voluntarily make, publish
and declare this to be my LIVING WILL, making known my desire that
my life shall not be artificially prolonged under the circumstances
set forth below, and do hereby declare:
l. This instrument is directed to my family, my physician(s), my
attorney, my clergyman, any medical facility in whose care I happen
to be, and to any individual who may become responsible for my health,
welfare or affairs.
2. Death is as much a reality as birth, growth, maturity and old
age. It is the one certainty of life. Let this statement stand as
an expression of my wishes now that I am still of sound mind, for
the time when I may no longer take part in decisions for my own
3. If at any time I should have a terminal condition and my attending
physician has determined that there can be no recovery from such
condition and my death is imminent, where the application of life-prolonging
procedures and "heroic measures" 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or withdrawn, and that I be permitted to die naturally. I do not
fear death itself as much as the indignities of deterioration, dependence
and hopeless pain. I therefore ask that medication be mercifully
administered to me and that any medical procedures be performed
on me which are deemed necessary to provide me with comfort, care
or to alleviate pain.
4. In the absence of my ability to give directions regarding the
use of such life-prolonging 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 for such refusal.
5. In the event that I am diagnosed as comatose, incompetent, or
otherwise mentally or physically incapable of communication, I appoint
______________________________ to make binding decisions concerning
my medical treatment.
6. If I have been diagnosed as pregnant and that diagnosis is known
to my physician, this declaration shall have no force or effect
during the course of my pregnancy.
7. I understand the full import of this declaration and I am emotionally
and mentally competent to make this declaration. I hope you, who
care for me, will feel morally bound to follow its mandate. I recognize
that this appears to place a heavy responsibility upon you, but
it is with the intention of relieving you of such responsibility
and of placing it upon myself, in accordance with my strong convictions,
that this statement is made.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed
my seal at _______________, _______________, this _____ day of ____________,
20____, in the presence of the subscribing witnesses whom I have
requested to become attesting witnesses hereto.
The declarant is known to me and I believe him/her to be of sound
Subscribed and acknowledged, before me by___________________ __________________________,
and subscribed and sworn to before the witnesses, on the _______day
of ____________________, 20___.
____________________________ (SEAL) NOTARY PUBLIC
State of ___________________
My Commission Expires: ____________________________
Copies of this instrument have been given to:
Receipt and acknowledged & date: