Simple Living Will Form
A simple living will form allows applicants to make decisions about their medical treatment should they become terminally ill to the point of being kept alive by life support systems. It applies when the illness causes the applicant to be in a permanently unconscious state of mind, or conscious but with irreversible brain damage. It is superseded by the applicant’s health care power of attorney.
Sample Living Will Form
- I want my life prolonged as long as possible within acceptable medical practice and standards.
- I direct that I receive whatever quantity of medication that may be required to keep me from pain and distress even if the moment of death is hastened.
This directive is signed by me on this ________________day of _______________20____ at __________________________ in the presence of the two undersigned witnesses.
Declaration of Witnesses
As witnesses we declare that the above named person is personally known to us, appears to be of sound mind and signed this directive willingly and free of undue influence or duress. We are legal adults and are not related to him / her by blood, marriage or adoption and are not appointed as agents in this directive. To our knowledge we are not beneficiaries of his / her estate and have no claims against his / her estate. We are not directly involved in his / her health care. We declare that he / she signed this will in our presence as we signed as witnesses in the presence of each other, all being present at the same time. Under penalty of perjury we declare these statements to be true and correct on this ___________________ day of ____________________ 20____ at _________________________________.
Witness 1.
Name: ______________________
Address: _____________________________________________
Signature: ________________________
Witness 2.
Name: ______________________
Address: _____________________________________________
Signature: ________________________
Category: Power of Attorney forms
