LIVING WILL
OF
[INSERT]
DATE:
KNOW ALL MEN BY THESE PRESENTS, THAT I, [INSERT NAME], being of full age and
sound mind and memory, do hereby MAKE, PUBLISH and DECLARE this instrument to be my
LIVING WILL:
In the event of my incapacity or inability to express my health care wishes for any reason, I
hereby affirm my desire and intent that my wishes be as follows:
ARTICLE I. DECLARATIONS
A. DOMICILE AND APPLICABLE LAWS
I declare that I am domiciled in [INSERT STATE NAME] and that in so far as possible the
interpretation and administration of this Living Will shall be guided or where applicable governed
by the relevant provisions of the [INSERT STATE LAWS].
B. DECLARATION OF INCAPACITY
Should I become incapable of making health care decisions for myself, I wish to be promptly
evaluated by [INSERT PHYSICIAN’S NAME], and I authorize him/her to release all pertinent
medical information to my designated agents.
ARTICLE II. APPOINTMENT OF HEALTH CARE PROXY
A. I nominate, constitute and appoint [INSERT APPOINTEE’S NAME] as my Health Care
Proxy to make all health care decisions on my behalf according to my wishes as stated
in this document, and in accordance with applicable laws if I can no longer make them
for myself.
B. If my Proxy is unable or unwilling to serve as Proxy, I appoint [INSERT ALTERNATE
PROXY’S NAME] as my alternate Proxy. In addition to any other powers that may be
conferred by law, I give my Proxy under this Will, including any successor or successors
thereto, those powers set forth in the Law.
ARTICLE III: FINANCIAL POWER OF ATTORNEY
I appoint [INSERT NAME] as my Financial Power of Attorney to manage my assets and
liabilities, pay my bills and taxes, and take all financial decisions on my behalf if I become
incapacitated.
ARTICLE IV. APPOINTMENT OF GUARDIAN
A. In the event of my death or incapacitation, and if it becomes necessary or desirable that
a guardian of my person or my children be appointed, then it is my wish and direction
that any court having jurisdiction appoints [INSERT GUARDIAN’S NAME] as the legal
guardian of my minor children, with full power to take all actions necessary to protect
their health, education and welfare.
B. If [INSERT GUARDIAN’S NAME] cannot or will not act as guardian, I direct that any
court having jurisdiction appoints [INSERT ALTERNATE GUARDIAN’S NAME] as a legal
guardian of my minor children.
ARTICLE V: MEDICAL TREATMENT
A. It is my desire to have all reasonable and necessary medical treatment provided to me in
order to prolong my life and alleviate my suffering in the event of a severe illness or
injury.
B. If I have an incurable and irreversible condition that results in my being permanently
unconscious, I direct that life-sustaining treatment be withheld or withdrawn, and that I
be permitted to die naturally.
ARTICLE VI: END-OF-LIFE DECISIONS
A. If my condition is terminal or if I am in a persistent vegetative state, and there is no hope
of recovery, I do not wish to be kept alive by extraordinary measures such as a ventilator
or feeding tube to prolong my life.
B. In such time, I direct that I be provided with comfortable care and treatment that serves
only to relieve my pain and suffering.
ARTICLE VII: ORGAN DONATION
If medically possible and after consultation with my family, I would like to donate all of my
organs and tissues that are deemed viable for purposes of transplantation, medical research
and education, in accordance with applicable laws, rules, and regulations.
ARTICLE IV: FUNERAL ARRANGEMENTS
I would like my children to make all arrangements regarding my funeral and burial. I have
discussed this with them and I trust that they will make the best decision.
ARTICLE XI: SEVERABILITY
If any provisions of this Will are deemed unenforceable, the remaining provisions shall remain in
full force and effect.
IN WITNESS WHEREFORE I, [INSERT NAME] the Principal/Declarant herein, have hereunto
set my hand on this [INSERT DATE] declaring this instrument as my Living Will, in the presence
of the undersigned witnesses, who witnessed and attested to this Living Will at my request and
in my presence.
SIGNED by the said}
[INSERT NAME]}
the Principal/Declarant herein as his/her LIVING WILL}
__________________________________
} PRINCIPAL/DECLARANT
In the presence of us both present at the same }
time who at his/her request in his/her presence }
and in the presence of each other have hereunto } 1. ___________________________
subscribed our names as witnesses: } WITNESS
}
} 2. ___________________________
} WITNESS
}
}
ACKNOWLEDGEMENT & AFFIDAVIT
STATE OF:
COUNTY OF:
I, the Principal/Declarant, declare to the officer taking my acknowledgment of this instrument,
and to the subscribing Witnesses, that I signed this instrument as my Living Will on the date set
forth above.
Signature of
Acknowledged and subscribed before me by the above-named Principal/Declarant who is
personally known to me or has produced as identification:
——————————————————————————————————————————-
;
and sworn to and subscribed before me by the above named First Witness who is personally
known to me or has produced as identification:
——————————————————————————————————————————-
;
and sworn to and subscribed before me by the above named Second Witness who is personally
known to me or has produced as identification:
——————————————————————————————————————————-
;
and subscribed by me in the presence of the Principal/Declarant and each of the subscribing
Witnesses.
Notary Public
Dated:
(Seal)
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