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Form #1129Living Will Declaration - Indiana
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Living Will, Indiana
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LIVING
WILL DECLARATION
           DECLARATION
made
this _________ day of ____________________________, 20______.
           I, ____________________,
being at least eighteen (18) years of age and of sound mind, willfully and
voluntarily make known by desires that my dying shall not be artificially
prolonged under the circumstances set forth below, and I declare:
           If at any time
my attending physician certifies in writing that:
1.  I
have an incurable injury, disease or illness;
2.  My
death will occur within a short time; and
3.  The
use of life prolonging 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such procedures be withheld or withdrawn and that I be permitted to die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 performance or provision of any medical procedure or
medication necessary to provide me with comfort care or to alleviate pain and,
if I have so indicated below, the provision of artificially supplied nutrition
and hydration (Indicate your choice by initialing or making your mark before
signing this declaration):
           ___________ I
wish to receive artificially supplied nutrition and hydration, even if the
effort to sustain life is futile or excessively burdensome to me.
           ___________ I
do not wish to receive artificially supplied nutrition and hydration, if the effort
to sustain life is futile or excessively burdensome to me.
           ___________ I
intentionally make no decision concerning artificially supplied nutrition and
hydration, leaving the decision to my health care representative appointed
under I.C. 16-36-1-7 or my attorney in fact with health care powers under I.C. 30-5-5-16 and I.C. 30-5-5-17.Â
           In the absence
of my ability to give directions regarding the use of life prolonging
procedures, it is my intention that this declaration be honored by my family
and physician as the final expression of my legal right to refuse medical or
surgical treatment and accept the consequences of the refusal.
          Â
           I understand the
full import of this declaration.
                                                                                   ___________________________________
                                                                                  Â
                                                                                  ___________________________________
                                                                                  City,
County and State of Residence
           _____________________
has been personally known to me, and I believe him/her to be of sound mind.
           I
did not sign his/her signature above for or at the direction of _________________.
          Â
           I
am not entitled to any part of ____________________ estate or directly
financially responsible for his/her medical care.
           I
am competent and at least eighteen (18) years of age.
DATED:
____________________________Â Â Â Â Â Â Â Â Â Â ___________________________________
                                                                                   WITNESS
DATED:
____________________________Â Â Â Â Â Â Â Â Â Â ___________________________________
                                                                                   WITNESS
Attorney Advertising
Dugan & Repay LLP
is only advertising in states where they are admitted to practice
|
Contributed by
Dugan & Repay LLP |
 |
|
Name of Firm |
Dugan & Repay LLP |
|
Profession |
Lawyer |
|
Number of lawyers in firm |
2 |
|
Branch of Law |
Personal Injury, Workers Compensation, Estate Planning, Family, Employment & Labor, |
|
Location |
Schererville,
Indiana,
United States |
|
Principal Office Address |
Dugan & Repay LLP
7656 Harvest Drive
Schererville, IN 46375 |
|
Practicing law since |
1/1/1997 |
|
Total Forms Contributed |
3 |
|
Phone |
2198649922 |
|
Website |
http://www.dr-legal.com |
|
Email |
|
|
Full service law firm |
State Advertising Disclaimer:
Dugan & Repay, LLP is only advertising in states where they are admitted to practice.
Dugan & Repay, LLP is only advertising in states where they are admitted to practice.
|
See All
Dugan & Repay LLP's Forms |
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legal council before engaging in any action based upon content contained on this
site.
These downloadable forms are only for personal use. Retransmission, redistribution,
or any other commercial use is prohibited. This includes reposting forms from this
site to another site offering free legal or other document forms for download.
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form, and you agree to abide by these terms. It is highly recommended that you have
a licensed attorney review any legal documents for which you are searching in order
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Your use of this site constitutes your acceptance of our terms of use and your agreement
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site. If you do not agree to the above terms, please do not proceed.
These forms are provided to assist business owners and others in understanding important
points to consider in different transactions. They are offered with the understanding
that no legal advice, accounting, or other professional service is being offered
by these documents or on this website. Laws vary in the different states. Agreements
acceptable in one state may not be enforced the same way under the laws of another
state. Also, agreements should relate specifically to the particular facts of each
situation. Therefore, it is important to consult legal counsel whenever utilizing
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is not engaged in recommending or referring members on the site or making claims
about the competence, character or qualifications of its participating members.
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