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  • In the event that the time comes, and I am incapacitated to the point that I am no longer able to actively take part in decisions for my own life, and I am unable to direct healthcare physician as to my own medical care. I hereby authorize this Living Will as my Advance Health Care Directive / Memorandum to stand as a testament of my wishes.
  • currently residing at
  • being of sound mind, and acting willingly and without duress, fraud or undue influence, hereby direct that the instructions provided herein are to recognized as a formal statement of my desires with regards to my healthcare, custody and medical treatment, and as such I hereby voluntarily declare and make this designation with regards to my living Will (aka Advance Health Care Directive and/or Health Care Proxy). These instructions and directives shall be binding upon all involved to the fullest allowable by law.

    I hereby appoint
  • currently residing at

  • as my advocate and agent to make any and all healthcare decisions on my behalf should I ever be diagnosed with a terminal illness, disease, injury which prevents me from making those decisions, or should I become incapacitated or permanently unconscious (in a coma or persistent vegetative condition) where I would remain permanently unable to make decisions.


    My healthcare advocate / agent shall have the power to make healthcare, custody, and medical treatment decisions on my behalf if my attending and or primary doctor makes the determination that I am unable to make those decisions.

    I have specific directives regarding the delivery of medical care in certain healthcare conditions. Therefore, I wish to direct my medical treatment by way of the following conditions.


    Should any of the foreseeable events should occur. I wish to have the following directives regarding the treatment and procedures which may be used, withheld, or withdrawn:
  • , any mouth-to-mouth resuscitation, artificial respiration, mouth to nose resuscitation or cardiac resuscitation (CPR) in an attempt to try and posing my life.
  • life-support (e.g., respirators, ventilators) or any other apparatus used in an effort to replace or support my natural breathing.
  • tube feeding, enteral nutrition, or any other artificial or invasive form of nutrition (food) or hydration (water).
  • blood or any other subsidiaries of blood products.
  • any form of surgery, incision, enucleation, or invasive diagnostic tests.
  • kidney dialysis or renal replacement therapy of any kind of this type of treatment.
  • antibiotics, medication or pharmaceutical products, in an attempt to try and prolong my life.

  • I totally understand without remorse, that if I do not specifically specify my preferences above condition regarding any of the forms of treatment mention. I may be subjected to that form of treatment.


    With regards to the aforementioned medical situations, I hereby provide the following directives memorandum pertaining to the comfort care and pain relief:
  • maximum pain relief medication known to internal medicine.
  • maximum pain relief medication if it unintentionally hastens my death, without remorse.
  • maximum pain relief medication, of any kind if it may result in temporary addiction, during my illness should I survive, recover, or rebound from my current conditions and or extended hospital stay, upon recovery.

    My appointed agent / advocate upon my wishes as indicated in this memorandum shall make healthcare decisions on my behalf in accordance with my wishes within this known document, known to my advocate and or agent, to the extent that my wishes are not known to my agent / advocate, my advocate / agent shall make the necessary healthcare decisions for me in accordance with what my agent / advocate, deems to be in my best interest. In determining in my best interests, that my agents / advocates shall take into consideration my personal values to the extent of this memorandum known to the agent / advocate.


    In this memorandum, I direct my healthcare agent / advocate, healthcare provider, as well as others who may be involved in my healthcare, to withhold or withdraw treatment in accordance with the choice I have indicated below in this memorandum.


    This instrument / memorandum, shall be governed by the laws of
  • , and I respectfully request that it be honored in any state in which I may reside at the time that my Living Will shall take effect.

    By signing this memorandum below, I certify that I am fully aware and completely understand the contents of this document without being coerce without intimidation or fear, and I am of sound body and mind. Furthermore, I am of the legal age of consent and not under influence, fraud, or duress.


    This Living Will (aka Advance Health Care Directive / Memorandum and or Health Care Proxy) must be signed by two adult witnesses that are personally present when I sign this document.


    I certify that we or I am 18 years of age or older and that I know the Declarant personally or have been provided with valid proof as to his / her/ partner identity and believe him / her / partner to be of sound mind and under no duress, fraud, or undue influence. The Declarant has had the opportunity to read this document and has signed or acknowledged his / her / partner signature or mark in my presence

    Under penalty of property, I declare that I am not related to the Declarant by blood, marriage, or adoption, nor am I responsible for his / her / partner medical care or costs. Furthermore, I am not the primary or attending physicians or an employee of the physician or other healthcare provider or current care facility for the Declarant. I also attest that I am not an employee of any life or health insurance provider, nor am I involved with the direct physical care of the Declarant. Further, I have no claim to the Declarant’s estate, and to the best of my knowledge, I am not entitled to any part of the Declarant’s estate upon his / her / partner death with any will now in existence or by any other process of law.
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  • , personally appeared before me and having provided verifiable identification to be the Declarant whose name is subscribed to this instrument and acknowledged me that s/he/partner executed the name in his / her / partner capacity, and that by his / her / partner signature on the instrument, executed the instrument.

    I declare that s/he/partner appears to be of sound mind and not under or subject to duress, fraud, or undue influence, that s/he/partner acknowledges the execution the same to be his / her / partner voluntary act deed, and that I am not the advocate, attorney-in-fact, proxy, surrogate, or a successor of any such, as designated within this document, not do I hold any interest in his / her / partner estate through a Will or by any other means or process of law.

    I also declare that I have been provided with verifiable identification for the above-mentioned witnesses whose names are subscribed to in this instrument, and hereby acknowledge their signatures as well.

    WITNESS my hand and seal.
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