Principal's name:
Address:
Date of birth:
Social security number:
Date of execution:
This Living Will (the "Will") shall be used when you can no longer provide your healthcare wishes to your doctors or other medical personnel.
This Will consists of:
I, , an individual having my usual place of living at and a social security number (the "Principal"), desire to advise my doctors and/or medical personnel of my wishes for my health care in the event I no longer have decisional capacity.
LIFE SUPPORT TREATMENT
I desire that my doctor make a concerted effort to return me to an acceptable quality of life using the available treatments and therapies. However, if my quality of life becomes unacceptable, as I have defined below, and my doctors have determined that my condition will not improve; namely, my health condition is irreversible, I direct that all treatments that extend my life shall be withdrawn.
Unacceptable quality of life means:
CERTAIN LIFE-SUSTAINING TREATMENT
I do not wish to have these life-sustaining treatments under any circumstances, even if recovery is a possibility:
END-OF-LIFE WISHES
When I am near death, I wish to .
ORGAN AND/OR TISSUE DONATION
Upon my death, I wish to make the following anatomical gift for purposes of transplantation, research, and/or education:
OTHER ISSUES
.
GOVERNING LAW. This Living Will shall be governed by the laws of the State of .
The Principal's name and signature
______________________________________
WITNESS ACKNOWLEDGMENT
Witness 1
Signature: __________________________
Name:
Address:
Phone number:
Witness 2
Signature: __________________________
Name:
Address:
Phone number:
NOTARY ACKNOWLEDGMENT
State of
Acting in the county of
Sworn to and subscribed before me on ___________________________.
___________________________________
Place for signature
______________________________________
Notary public's name and seal