Living will made this day of (month, year).
I, , being of sound mind, willfully and voluntarily declare
that I want my wishes to be respected if I am very sick and not able to communicate my wishes for myself. In the
absence of my ability to give directions regarding the use of life-prolonging medical intervention, it is my desire
that my dying shall not be prolonged under the following circumstances:
If I am very sick and not able to communicate my wishes for myself and I am certified by one physician, who has
personally examined me, to have a terminal condition or to be in a persistent vegetative state (I am unconscious
and am neither aware of my environment nor able to interact with others), I direct that life-prolonging medical
intervention that would serve solely to prolong the dying process or maintain me in a persistent vegetative state
be withheld or withdrawn. I want to be allowed to die naturally and only be given medications or other medical
procedures necessary to keep me comfortable. I want to receive as much medication as is necessary to alleviate
my pain.
I give the following SPECIAL DIRECTIVES OR LIMITATIONS: (Comments about tube feedings, breathing
machines, cardiopulmonary resuscitation, dialysis and mental health treatment may be placed here. My failure to
provide special directives or limitations does not mean that I want or refuse certain treatments.)
It is my intention that this living will be honored as the final expression of my legal right to refuse medical or
surgical treatment and accept the consequences resulting from such refusal.
I understand the full import of this living will.
I did not sign the principal’s signature above for or at the direction of the principal. I am at least eighteen years
of age and am not related to the principal by blood or marriage, entitled to any portion of the estate of the princi-
pal to the best of my knowledge under any will of principal or codicil thereto, or directly financially responsible
for principal’s medical care. I am not the principal’s attending physician or the principal’s medical power of at-
torney representative or successor medical power of attorney representative under a medical power of attorney.
Witness DATE
Witness DATE
I, , a Notary Public of said County, do certify that ,
as principal, and and , as witnesses, whose names are
signed to the writing above bearing date on the day of , 20 ,have this day acknowledged
the same before me.
Given under my hand this day of , 20 .
My commission expires:
Notary Public
(h) A medical power of attorney may, but need not, be in the following form, and may include other specific direc-
tions not inconsistent with other provisions of this article. Should any of the other specific directions be held to be
invalid, such invalidity shall not affect other directions of the medical power of attorney which can be given effect
without invalid direction and to this end the directions in the medical power of attorney are severable.