I, ______________________________________________, residing at _______________________
__________________________________________, being of sound mind, willfully and voluntarily direct that my dying shall not be artificially prolonged under the circumstances set forth in this Declaration:

If at any time I should have an incurable injury, disease or illness certified to be a terminal condition by two (2) physicians who have personally examined me, one (1) of whom shall be my attending physician, and the physicians have determined that my death is imminent and will occur whether or not life-sustaining procedures are utilized and where the application of such procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, the natural administration of food and water (excluding administration by intubation), and the performance of any medical procedure that is necessary to provide comfort, care or alleviate pain. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this Declaration shall be honored by my family and physician (s) as the final expression of my right to control my medical care and treatment.

I am legally competent to make this Declaration, and I understand its full import.

Witness my hand and seal, this ______________day of ______________________, 19______.

_________________________________(SEAL)

UNDER THE PENALTIES OF PERJURY, we state that this Declaration was signed by ____________________________________________ in the presence of the undersigned, who at his request, in his presence, and in the presence of each other, have hereunto signed our names and witnessed this ___________day of ______________________, 19_______, and DECLARE:
The Declarant is personally known to me, and I believe the Declarant to be of sound mind. I did not sign the Declarant's signature to this Declaration. Based upon information and belief, I am not related to the Declarant by blood or marriage, a creditor of the Declarant, entitled to any portion of the estate of the Declarant under any existing testamentary instrument of the Declarant, financially or otherwise responsible for the Declarant's medical care, or an employee of any such person or institution.

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