Living Will and Durable Power of Attorney

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LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Date of Directive: .............................................................

Name of person executing Directive: ....................................................................................

Address of person executing Directive: .................................................................................

A LIVING WILL

A Directive to Withhold or to Provide Treatment

1. Being of sound mind, I willfully and voluntarily make known my desire that my life shall not be prolonged artificially under the circumstances set forth below. This Directive shall only be effective if I am unable to communicate my instructions and:

1. I have an incurable injury, disease, illness or condition and two (2) medical doctors who have examined me have certified:
   1. That such injury, disease, illness or condition is terminal; and
   2. That the application of artificial life-sustaining procedures would serve only to artificially prolong my life; and
   3. That my death is imminent, whether or not artificial life-sustaining procedures are employed; or
2. I have been diagnosed as being in a persistent vegetative state.

In such event, I direct that the following marked expression of my intent be followed, and that I receive any medical treatment or care that may be required to keep me free of pain or distress.

Check one box and initial the line after such box: 

............. I direct that all medical treatment, care and procedures necessary to restore my health, sustain my life, and to abolish or alleviate pain or distress be provided to me. Nutrition and hydration, whether artificial or non-artificial, shall not be withheld or withdrawn from me if I would likely die primarily from malnutrition or dehydration rather than from my injury, disease, illness or condition.

OR 

....... I direct that all medical treatment, care and procedures, including artificial life-sustaining procedures, be withheld or withdrawn, except that nutrition and hydration, whether artificial or non-artificial shall not be withheld or withdrawn from me if, as a result, I would likely die primarily from malnutrition or dehydration rather than from my injury, disease, illness or condition, as follows: (If none of the following boxes are checked and initialed, then both nutrition and hydration, of any nature, whether artificial or non-artificial, shall be administered.)