Statutory Declaration In Conformance With Illinois Natural Death

Statutory declaration in conformance with illinois natural death.

ACT, IL. STAT. 110 1/2 PARAGRAPH 703

DECLARATION OF Please state the name of the declarant

This declaration is 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 moment of death shall not be artificially postponed.

If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal condition by my attending physicians who has personally examined me, and has determined that my death is imminent except for death delaying procedures, I direct that such procedures which would serve only to prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide me with comfort care.

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

________________________________________ Please state the name of the declarant

City of Residence: Please state the city where signed County of Residence: Please state the county where signed State of Residence: Please state the state where signed

Date: __________________________________

Witness _________________________________________________

Witness _________________________________________________

Date: ___________________________________