If the time comes when I am incapacitated to the point where I can no longer actively take part in decisions for my own life, and am unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes. I State the Name of the Declarant request that I be allowed to die and not be kept alive through life support system if my condition is deemed terminal. I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.
This request is made, after careful reflection, while I am of sound mind.
State the Name of the Declarant