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With appointment of
proxy.Â
Declaration
If I should have an incurable and irreversible
condition that, without the administration of life-sustaining treatment, will,
in the opinion of my attending physician, cause my death within a relatively
short time, and I am no longer able to make decisions regarding my medical
treatment, I appoint _________ or, if he or she is not reasonably available or
is unwilling to serve, _________, to make decisions on my behalf regarding
withholding or withdrawal of treatment that only prolongs the process of dying
and is not necessary for my comfort or to alleviate pain, pursuant to the
Uniform Rights of the Terminally Ill Act of this State.
[If the individual(s) I have so appointed is not
reasonably available or is unwilling to serve, I direct my attending physician,
pursuant to the Uniform Rights of the Terminally Ill Act of this State, to
withhold or withdraw treatment that only prolongs the process of dying and is
not necessary for my comfort or to alleviate pain.] (Strike out bracketed
language if you do not desire it.)
Signed this _________ day of _________, _________.
Signature
_________
Address _________
The declarant voluntarily signed this writing in my
presence.
Witness
_________
Address _________
Witness _________
Address _________
Name and address of designees.
Name
_________
Address _________
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Your use of this site constitutes your acceptance of our terms of use and your agreement
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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
these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com
is not engaged in recommending or referring members on the site or making claims
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