vegetative state.  I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration in accordance with my specifications set forth below: 

______  If my condition is determined to be terminal and incurable, I authorize the following:

______  My physician may withhold or discontinue extraordinary means only.

______  In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.

______  If my physician determines that I am permanently in a coma, suffer severe dementia, or am in a persistent vegetative state, I authorize the following:

______  My physician may withhold or discontinue extraordinary means only.

______  In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.

This the _________ day of _______________ (month), ______ (year).

___________________________________ (Seal)

I hereby state that the declarant, __________________________________, being of sound mind, signed the above declaration in my presence and that I am not related to the declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir under the Intestate Succession Act if the declarant died on this

date without a will.  I also state that I am not the declarant's attending physician or an employee of the declarant's attending physician, or an employee of a health care facility in which the declarant is a patient or an employee of a nursing home or any group home where the declarant resides.  I further state that I do not now have any claim against the declarant.

_________________________                   _______________

Witness                                                         Date

_________________________                   _______________

Witness                                                         Date

I, _____________________________, a Notary Public for _________________ County, hereby certify that _____________________________________, the declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is ________________ (His/Her) Declaration of a Desire for a Natural Death, and that ____ (He/She) had willingly and voluntarily made and executed it as a free act and deed for the purposes expressed in it.

I further certify that ___________________________________________________ and _____________________________________, witnesses, appeared before me and swore that they witnessed ________________________________________, declarant, sign the attached declaration, believing __________ (Him/Her) to be of sound mind; and also swore that at the time they witnessed the declaration (i) they were not related within the third degree to the declarant or to the declarant's spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon the declarant's death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the declarant or an employee of an attending physician or an

employee of a health facility in which the declarant was a patient or an employee of a nursing home or any group home in which the declarant resides, and (iv) they did not have a claim against the declarant.  I further certify that I am satisfied as to the genuineness and due execution of the declaration.

This the __________ day of ________________ (month), _____(year).

___________________________________

Notary Public

My Commission Expires: ___________________