residing at _______________________
If at any time I should have an incurable injury, disease or illness certified to be a terminal condition by two (2) physicians who have personally examined me, one (1) of whom shall be my attending physician, and the physicians have determined that my death is imminent and will occur whether or not life-sustaining procedures are utilized and where the application of such procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, the natural administration of food and water (excluding administration by intubation), and the performance of any medical procedure that is necessary to provide comfort, care or alleviate pain. 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 right to control my medical care and treatment.
I am legally competent to make this Declaration, and I understand its full import.
Witness my hand and seal, this ______________day of ______________________, 19______.
UNDER THE PENALTIES OF PERJURY, we state that
this Declaration was signed by ____________________________________________
in the presence of the undersigned, who at his request, in his presence,
and in the presence of each other, have hereunto signed our names and
witnessed this ___________day of ______________________, 19_______,