Declaration made this __________ Day of ________ ______, _______________. I, _________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below and do hereby declare:

If at any time I should either have a terminal and irreversible incurable injury, disease or illness or be in a continual profound comatose state with no reasonable chance of recovery, certified 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procedures would only serve to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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 physician(s) 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.

Signed:

(Signature)

(Address)

(City)

(County)

(State)

The declarant has been personally known to me and I believe her to be of sound mind.

Witness: Date:

Witness: Date: