DECLARATION

If I should have an incurable or irreversible condition that will cause my death within a reasonable 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. It is my intention that this declaration shall be valid until revoked by me.

Signed this ___________________ day of ______________

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Signature - 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

The declarant is known to me and voluntarily signed this

document in my presence.

Witness:

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Witness:

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