UNIFORM LIVING WILL OF [list name of declarant]
To my family, physician, attorney, and anyone else who may become responsible for my health, welfare or affairs, I make this declaration while I am of sound mind.
If I should ever become in a 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 full reflection and is in accordance with my full desires. I want the above provisions carried out to the extent permitted by law. Insofar as they are not legally enforceable, I wish that those to whom this will is addressed will regard themselves as morally bound by this instrument.
If permissible in the jurisdiction in which I may be hospitalized I direct that in the event of a terminal diagnosis, that the physicians supervising my care discontinue feeding should the continuation of feeding be judged to result in unduly prolonging a natural death.
If permissible in the jurisdiction in which I may be hospitalized I direct that in the event of a terminal diagnosis, that the physicians supervising my care discontinue hydration (water) should the continuation of hydration be judged to result in unduly prolonging a natural death.
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.
I herewith release any and all hospitals, physicians, and others for myself and for my estate from any liability for complying with this instrument.
Signed:
_______________________________________________________________
[list
name of declarant]
City of residence: [city of residence]
County of
residence: [county of residence]
State of residence: [state of residence]
Social Security Number: [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 [list name of 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 [list name
of declarant], declarant, and in his presence, and that [list name of 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 __________________________________, 20_____.
My commission expires: __________________
___________________________________
Notary Public