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Directive made [date]. I, [name], residing in [county, state], being of sound mind, willfully and voluntarily make known my desire that my life shall, not be artificially prolonged under the circumstances set forth below, do hereby declare:
1. Directed Treatment. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally.
2. Inability to Give Directions. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this Directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
[Optional Paragraph 2b]
2b. Pregnancy. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this Directive shall have no force or effect during the course of my pregnancy.
3. Terminal Condition. I have been diagnosed and notified within the previous [number] days as having a terminal condition by [physician's name], MD, whose address is [address], and whose telephone number is [number]. I understand that if I have not filled in the physician's name and address, it shall be presumed that I did not have a terminal condition when I made out this Directive.
4. Term of Directive. This Directive shall have no force or effect [number] years from the date filled in above.
5. Mental and Emotional Competence. I understand the full import of this Directive, and I am emotionally and mentally competent to make this Directive.
[city, county, and state of residence]
This declarant has been personally known to me, and I believe him to be of sound mind.
[name of witness]
Residing at [address]
[name of second witness]
Residing at [address]
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]