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Important
Note:
Forms are to be used as a guide only to assist you. No liability is assumed for errors in substance or form. It is your responsibility to revise the forms to meet current law
requirements and your particular situation. No liability is assumed for improper use of these forms.
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LIVING
WILL (FEMALE)
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employed, I direct that such measures and procedures be withheld or withdrawn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. If I have
been diagnosed as pregnant and such diagnosis is known to my physicians, this
directive shall
have no force or effect during the course of my pregnancy.
4. I am
mentally, emotionally and legally competent to make this directive and I fully
understand its
import.
5. I reserve the
right to revoke this directive at any time.
6. This
directive shall remain in force until revoked.
IN WITNESS
WHEREOF, I have hereto set my hand and seal this _
(3)_ day of
________________, 19____.
______________________________
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.
_______________________________
______________________________
_______________________________
_____________________________
______________________________
_____________________________
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