ACT, AL.CODE 22-8A-4

DECLARATION OF Please state the name of the declarant

Declaration 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 dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:

If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life- sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary too provide me with comfort care.

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

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

________________________________________

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: __________________________________

The declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the declarant's signature above for or at the declaration of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil thereto, or directly financially responsible for declarant's medical care.

Witness ______________________________________________

Witness ______________________________________________

Date: ___________________________________________