Declaration As Provided By Alaska Statues, Sec 18.12.010

Declaration as provided by alaska statues, sec 18.12.010.

DECLARATION of Please state the name of the declarant

If I should have an incurable or irreversible condition that

will cause my death within a relatively short time, it is my

desire that my life not be prolonged by administration of life-

sustaining procedures.

If my condition is terminal and I am unable to participate in

decisions regarding my medical treatment, I direct my attending

physician to withhold or withdraw procedures that merely prolong

the dying process and are not necessary to my comfort or to

alleviate pain.

I do [ ] do not [ ] desire that nutrition or hydration (food

and water) be provided by gastric tube or intravenously if

necessary.

Signed this______ day of _____________________, 19______________

Signature:

________________________________________________________________

Please state the name of the declarant

Place of signing: Please state the Place where signed

The declarant is known to me and voluntarily signed or

voluntarily directed another to sign this document in my

presence

Witness:

________________________________________________________________

Signature

Address:

________________________________________________________________

Signature

Address:

State of _________________________

__________________________________ Judicial District

The foregoing instrument was acknowledged before me this

________________________________________, 19_________________ by

Please state the name of the declarant.

_________________________________________

Signature of person taking acknowledgment