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Living Will Declaration

Honoring Traditions and Creating New Ones


To My Family, Physician and Medical Facility

I, __________________________________ being of sound mind, voluntarily make known my desire that my dying shall not be artificially prolonged under the following circumstances:

If I should have an injury, disease or illness regarded by my physician as incurable and terminal, and if my physician determines that the application of life sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn and that I be permitted to die. I desire only treatment limited to those measures that will provide me with maximum comfort and freedom from pain. Should I become unable to participate in decisions with respect to my medical treatment,it is my intention that these directions be honored by my family and physician(s). I exercise my right to express my legal right to refuse medical treatment, and I accept the consequences of this refusal. Should I become comatose, incompetent or otherwise mentally or physically incapable of communication, I authorize ____________________________________ to make treatment decisions on my behalf in accordance with my Living Will Declaration. I have discussed my wishes concerning terminal care with this person, and I trust his judgement on my behalf.





State of ______________________________

County of ____________________________


In witness whereof the signature of the above named _________________________, has been affixed this ____________ day of _________________________ 20________.




Notary Public My Commission expires  ____________________