Apr 12, 2018 | Global Documents |
OF [STATE THE NAME OF THE DECLARANT] To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to be. To any individual who may become responsible for my health, welfare or affairs. Death is as much a reality as birth, growth, maturity and old age -- it is the one certainty of life. If the time comes when I, [STATE THE NAME OF THE DECLARANT], can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes while I am still of sound mind. If the situation should arise in which I am in terminal state and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I do, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life. This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that those to whom this will is addressed will regard themselves as morally bound by these provisions. If it is permissible under the laws of the jurisdiction in which I may be hospitalized I direct that the physicians supervising my care upon a terminal diagnosis to discontinue hydration (water) should the continuation of hydration be judged to result in unduly prolonging a natural death. If it is permissible under the laws of the jurisdiction in which I may be hospitalized I direct that the physicians supervising my care upon a terminal diagnosis to discontinue feeding should the continuation of hydration be judged to result in unduly prolonging a natural death. I herewith release any and all hospitals, physicians, and others both for myself and for my estate from any and all liability for complying with this declaration, to the fullest extent provided by law. I herewith authorize my spouse, if any, or any relative who is related to me within the third degree to effectuate my transfer from any hospital or other health care facility in which I may be receiving care should that facility decline or refuse to effectuate the instructions given herein. Signed: _______________________________________________________________ [STATE THE NAME OF THE DECLARANT] City of residence: [STATE DECLARANT'S CITY OF RESIDENCE] County of residence: [STATE THE DECLARANT'S COUNTY OF RESIDENCE] State of residence: [STATE THE DECLARANT'S STATE OF RESIDENCE] Social Security Number: [STATE THE DECLARANT'S SOCIAL SECURITY NUMBER] Date: _________________ ________________________________________________________________ Witness: ________________________________________________________________ Witness: STATE OF ________________________ COUNTY OF _______________________ This day personally appeared before me, the undersigned authority, a Notary Public in and for ______________ County, ___________________________State, ______________________________ _______________________________(Witnesses) who, being first being duly sworn, say that they are the subscribing witnesses to the declaration of [STATE THE NAME OF THE DECLARANT], the declarant, signed, sealed and published and declared the same as and for his declaration, in the presence of both these affiants; and that these affiants, at the request of said declarant, in the presence of each other, and in the presence of said declarant, all present at the same time, signed their names as attesting witnesses to said declaration. Affiants further say that this affidavit is made at the request of [STATE THE NAME OF THE DECLARANT], declarant, and in his presence, and that [STATE THE NAME OF THE DECLARANT] at the time the declaration was executed, in the opinion of the affiants, of sound mind and memory, and over the age of eighteen years. Taken, subscribed and sworn to before me by ____________ ___________ (witness) and ____________________________ (witness) this _______ day of __________________________________, 19_____. My commission expires: __________________ ___________________________________ Notary Public
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