Declaration of intent provided by Mississippi Code 41-41-107.
SEC. 41-41-107. Declaration of intent; form.
(1) The authorization for withdrawal of life-sustaining mechanisms must be a declaration signed by at least two (2) persons who witnessed the execution of the declaration by the declarant which shall be in substantially the following form:
DECLARATION made on [Date] by [Person's Name] of [Address of Person], [Social Security Number of Person].
I, Please state the name of the declarant, being of sound mind, declare that if at any time I should suffer a terminal physical condition which causes me severe distress or unconsciousness, and my physician, with the concurrence of two (2) other physicians, believes that there is no expectation of my regaining consciousness or a state of health that is meaningful to me and but for the use of life-sustaining mechanisms my death would be imminent, I desire that the mechanisms be withdrawn so that I may die naturally. However, if I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy. I further declare that this declaration shall be honored by my family and my physician as the final expression of my desires concerning the manner in which I die.
SIGNED: Please state the name of the declarant
I hereby witness this declaration and attest that:
(1) I personally know the declarant and believe the Declarant to be of sound mind.
(2) To the best of my knowledge, at the time of the execution of this declaration, I:
(a) Am not related to the Declarant by blood or marriage,
(b) Do not have any claim on the estate of the Declarant,
(c) Am not entitled to any portion of the Declarant's estate by any will or operation of law, and
(d) Am not a physician attending the declarant or a person employed by a physician attending the declarant.
WITNESS [Signature of Witness #1]
ADDRESS [Address of Witness #1]
SOCIAL SECURITY NUMBER [Social Security Number of Witness #1]
WITNESS [Signature of Witness #2]
ADDRESS [Address of Witness #2]
SOCIAL SECURITY NUMBER [Social Security Number of Witness #2]
(2) The declaration shall be filed with the bureau of vital statistics of the state board of health.
Laws, 1984, ch. 365, Sec. 4, eff from and after July 1, 1984.