Living Will
This Living Will is made as per the laws of the State of [State Name]. Please ensure you have filled in all relevant information.
Personal Information:
- Name: ____________________________
- Date of Birth: ______________________
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- City: _____________________________
- State: ____________________________
- Zip Code: _________________________
Declaration:
I, [Your Full Name], being of sound mind, willfully and voluntarily make this declaration to document my wishes regarding medical care in the event that I am unable to communicate them.
Instructions:
- If I become terminally ill or permanently unconscious, I do not want life-sustaining treatment if:
- There is no reasonable chance of recovery.
- My quality of life is severely compromised.
- In addition, I wish to refuse:
- Artificial nutrition and hydration.
- Respiratory support.
- Any procedures deemed futile and not in line with my wishes.
Nominating an Agent:
I hereby appoint [Agent's Name] as my health care agent. If [Agent's Name] is unable or unwilling to serve, I appoint [Alternate Agent's Name].
Signature:
Signature: __________________________ Date: __________
Witness 1: _________________________ Date: __________
Witness 2: _________________________ Date: __________
This Living Will shall be effective immediately upon my incapacitation, in accordance with the laws of the State of [State Name].