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Statutory Advance Directive In Conformance With West Virginia Code - Version 1

Statutory Advance Directive in conformance with West Virginia Code. CHAPTER 16: Public Health;
ARTICLE 30: West Virginia Health Care Decisions Act. http://www.legis.state.wv.us/wvcode/code.cfm?ch...


DECLARATION OF Please state the name of the declarant

Declaration made this __________ day of ________________

19________. I, Please state the name of the declarant, being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, do declare:

If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur whether or not life- sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of nutrition, medication or the performance of any medical procedure deemed necessary to provide me with comfort, care or to alleviate pain.

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.


Signature- Please state the name of the declarant

Address: Please state the street address of declarant

Please state the city, state of declarant

I did not sign the declarant's signature above for or at the direction of the declarant. I am at least eighteen years of age and am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession of the State of West Virginia, or to the best of my knowledge under any will of declarant or codicil thereto, or directly financially responsible for declarant's medical care. I am not the declarant's attending physician, an employee of the attending physician, nor an employee of the health facility in which the declarant is a patient.





STATE OF ________________________

COUNTY OF _______________________

This day personally appeared before me, the undersigned

authority, a Notary Public in and for ______________ County,

___________________________State, ______________________________

_______________________________(Witnesses) who, being first being duly sworn, say that they are the subscribing witnesses to the declaration of Please state the name of the declarant, the declarant, signed, sealed and published and declared the same as and for his declaration, in the presence of both these affiants; and that these affiants, at the request of said declarant, in the presence of each other, and in the presence of said declarant, all present at the same time, signed their names as attesting witnesses to said declaration.

Affiants further say that this affidavit is made at the request of Please state the name of the declarant, declarant, and in his presence, and that Please state the name of the declarant at the time the declaration was executed, in the opinion of the affiants, of sound mind and memory, and over the age of eighteen years.

Taken, subscribed and sworn to before me by ____________

___________ (witness) and ____________________________ (witness)

this _______ day of __________________________________, 19_____.

My commission expires: __________________


Notary Public