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 freedom from pain.

Signed this _______________ day of _______________, 19_____

Signature:

________________________________________________________________

The declarant is known to me and voluntarily signed this

document in my presence.

Witness:

________________________________________________________________

Address:

Witness:

________________________________________________________________

Address: