Sample Uniform Living Will
To my children, my family, my physician, my lawyer, my accountant, my friends. To any medical facility in whose care I happen to be. To any individual who may become responsible for my health, welfare or affairs.
Death is as much a reality as birth, growth, maturity and old age -- it is the one certainty of life. If the time comes when I, (Name), can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes while I am still of sound mind.
If the situation should arise in which I am in terminal state and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I do, however, ask that medication be mercifully administered to me to alleviate pain and suffering even though this may shorten my remaining life.
This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that those to whom this will is addressed will regard themselves as morally bound by these provisions.
If it is permissible under the laws of the jurisdiction in which I may be hospitalized I direct that the physicians supervising my care upon a terminal diagnosis to discontinue hydration (water) should the continuation of hydration be judged to result in unduly prolonging a natural death.
If it is permissible under the laws of the jurisdiction in which I may be hospitalized I direct that the physicians supervising my care upon a terminal diagnosis to discontinue feeding should the continuation of hydration be judged to result in unduly prolonging a natural death.
I herewith release any and all hospitals, physicians, and others both for myself and for my estate from any and all liability for complying with this declaration, to the fullest extent provided by law.
I herewith expressly authorize my children, or any relative who is related to me within the third degree, and my physician, my lawyer, my accountant, my friends, any clergy, and any medical facility in whose care I happen to be, and any individual who may become responsible for my health, welfare or affairs, to effectuate my transfer from any hospital or other health care facility in which I may be receiving care should that facility decline or refuse to effectuate the instructions given herein.
I herewith affix my signature to this Uniform Living Will of (Name) on this the ___ day of Month, Year at Address, in the presence of the following witnesses, who witnessed and subscribed this Uniform Living Will at my request, and in my presence.
Signed:
_______________________________________________________________ Name
City of residence:
County of residence:
State of residence:
Social Security Number:
Date: _________________
ATTESTATION CLAUSE
On the date above written, (Name) , well known to us declared to us, and in our presence, that this instrument, Uniform Living Will of (Name) , consisting of three (3) pages, is his/her Uniform Living Will, and , then signed this instrument in our presence, and at 's request we now sign this will as witnesses in each other's presence. Further that (Name) , appeared to us to be of sound mind and lawful age, and under no undue influence.
Witness:
______________________________________________________________
Address: ______________________________________________________
Witness:
______________________________________________________________
Address: _____________________________________________________
Witness: ______________________________________________________________
Address: ______________________________________________________
AFFIDAVIT
STATE OF )
COUNTY OF )
Before me, the undersigned authority authorized to take acknowledgments and administer oaths, personally appeared:
______________________________________
(Name) , SS No.
_______________________________________
(Witness)
_______________________________________
(Witness)
_______________________________________
(Witness)
who after being having duly sworn or affirmed to tell the truth, stated:
1. That (Name) declared this instrument to be his/her Uniform Living Will to the witnesses.
2. That (Name) signed this instrument in their presence.
3. That the witnesses signed as witnesses in the presence of (Name) and each other.
4. That (Name) is well known to the witnesses, and the witnesses believe (Name) to be of lawful age, of sound mind and under no undue influence or constraint.
______________________________________________________________ Officer:
Title of Officer: _________________________________________
My Commission Expires: _____________________
If you have any questions regarding the information in this document, please consult your legal professional.
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