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I, __________(1)_____________, of ___________(2)____________, being of sound
mind, do hereby willfully and voluntarily make known my desire that my life not be prolonged
under any of the following conditions, and do hereby further declare:
1. If I should, at any time, have an incurable condition caused by any disease or illness,
or by any accident or injury, and be determined by any two or more physicians to be in a terminal
condition whereby the use of "heroic measures" or the application of life-sustaining procedures
would only serve to delay the moment of my death, and where my attending physician has
determined that my death is imminent whether or not such "heroic measures" or life-sustaining
measures are employed, I direct that such measures and procedures be withheld or withdrawn
and that I be permitted to die naturally.
2. In the event of my inability to give directions regarding the application of life-sustaining
procedures or the use of "heroic measures", it is my intention that this directive shall be honored
by my family and physicians as my final expression of my right to refuse medical and surgical
treatment, and my acceptance of the consequences of such refusal.
3. If I have been diagnosed as pregnant and such diagnosis is known to my physicians,
this directive shall have no force or effect during the course of my pregnancy.
4. I am mentally, emotionally and legally competent to make this directive and I fully
understand its import.
5. I reserve the right to revoke this directive at any time.
6. This directive shall remain in force until revoked.
IN WITNESS WHEREOF, I have hereto set my hand and seal this _(3)_ day of _______
(4)_______, ___(5)_.
Declaration of Witnesses
The declarant is personally known to me and I believe her to be of sound mind and
emotionally and legally competent to make the herein contained Directive to Physicians. I am not
related to the declarant by blood or marriage, nor would I be entitled to any portion of the
declarant's estate upon her decease, nor am I an attending physician of the declarant, nor an
employee of the attending physician, nor an employee of a health care facility in which the
declarant is a patient, nor a patient in a health care facility in which the declarant is a patient, nor
am I a person who has any claim against any portion of the estate of the declarant upon her
____________(7)_________________ _____________(8)_______________
____________(9)_________________ _____________(10)______________
___________(11)_________________ _____________(12)______________

The information in this document is designed to provide an outline that you can follow
when formulating business or personal plans. Due to the variances of many local, city, county
and state laws, we recommend that you seek professional legal counseling before entering into
any contract or agreement.