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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measures and procedures be withheld or withdrawn and that I be permitted to die naturally.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.
____________(7)_________________ _____________(8)_______________
____________(9)_________________ _____________(10)______________
___________(11)_________________ _____________(12)______________
NOTICE
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.
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