I, _______________________, of _______________________, 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procedures be withheld or withdrawn and that I be permitted to die naturally. 2.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 __ day of ______________, 20__. ____________________________
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. _____________________________ ____________________________ _____________________________ ___________________________ ____________________________ ___________________________
Where can you find a free living will form that you can print? At max-info.com