Living Will (Male)
I, __________(1)_____________, of ___________(2)____________, being
of sound mind, do hereby willfully and voluntarily make known my
desire that my life not be prolonged under any of the following
conditions, and do hereby further declare:
1. If I should, at any time, have an incurable condition caused
by any disease or illness, or by any accident or injury, and be
determined by any two or more physicians to be in a terminal condition
whereby the use of "heroic measures" or the application
of life-sustaining procedures would only serve to delay the moment
of my death, and where my attending physician has determined that
my death is imminent whether or not such "heroic measures"
or life-sustaining measures are employed, I direct that such measures
and procedures be withheld or withdrawn and that I be permitted
to die naturally.
2. In the event of my inability to give directions regarding the
application of life-sustaining procedures or the use of "heroic
measures", it is my intention that this directive shall be
honored by my family and physicians as my final expression of my
right to refuse medical and surgical treatment, and my acceptance
of the consequences of such refusal.
3. I am mentally, emotionally and legally competent to make this
directive and I fully understand its import.
4. I reserve the right to revoke this directive at any time.
5. This directive shall remain in force until revoked.
IN WITNESS WHEREOF, I have hereto set my hand and seal this _(3)_
day of _______(4)_______, 19_(5)_.
______________(6)______________ Declaration of Witnesses
The declarant is personally known to me and I believe him to be
of sound mind and emotionally and legally competent to make the
herein contined Directive to Physicians. I am not related to the
declarant by blood or marriage, nor would I be entitled to any portion
of the declarant's estate upon his decease, nor am I an attending
physician of the declarant, nor an employee of the attending physician,
nor an employee of a health care facility in which the declarant
is a patient, nor a patient in a health care facility in which the
declarant is a patient, nor am I a person who has any claim against
any portion of the estate of the declarant upon his death.
The information in this document is designed to provide an outline
that you can follow when formulating business or personal plans. Due
to the variances of many local, city, county and state laws, we recommend
that you seek professional legal counseling before entering into any
contract or agreement.