LIVING WILL DECLARATION
RELATIVE TO THE USE OF LIFE-SUSTAINING
PROCEDURES

     If I should have an incurable or irreversible condition that will result either in death within a relatively short period of time or a state of permanent unconsciousness from which, to a reasonable degree of certainty, there can be no recovery, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If I am unable to participate in my health care decisions, I direct my attending physician to withhold or withdraw life-sustaining procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.

DECLARANT SIGNATURE

Signed this                                  day of                                         ,              .
Signature of Declarant:                                                                                       
Type or Print Name of Declarant:                                                                         
Address:                                                                                                           
                                                                                                                         

WITNESS SIGNATURES

     I declare under penalty of perjury that the person who signed this document is personally known to me to be the Declarant; that the Declarant signed this Declaration in my presence; or directed another person to sign this document on his/her behalf in my presence; that I signed this document in the presence of the Declarant and in the presence of the other undersigned witnesses; that the Declarant appears to be of sound mind and under no duress, fraud, or undue influence; that I am eighteen (18) years of age or older; that I am not a health care provider attending the Declarant on the date of execution of this Declaration; nor am I an employee of the treating health care provider on the date of execution of this Declaration.
First Witness' Signature:                                                                                    
First Witness' Printed Name:                                                                              
Address:                                                                                                           
                                                                                                                        
Second Witness' Signature:                                                                               
Second Witness' Printed Name:                                                                         
Address:                                                                                                           
                                                                                                                         

ADDITIONAL WITNESS SIGNATURE
(AT LEAST ONE OF THE TWO WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION)

     I further declare under penalty of perjury that I am not related to the Declarant by blood, marriage or adoption within the third degree of consanguinity.

Signature:                                                                                                          

Signature:                                                                                                          

OR
NOTARY

On this                    day of                                 , in the year              before me the undersigned, a Notary Public in and for the State of                      , personally appeared                                  (the Declarant) personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument; and acknowledged that he or she executed it as his or her voluntary act or deed.
     I declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence, and that I am satisfied as to the genuineness and due execution of this document.

(NOTARY SEAL)