I, __________, being of sound mind, make this declaration to state my wishes if I become unable to make my own medical decisions.

1. Life-Sustaining Treatment

If I have a terminal condition or am permanently unconscious: __________.

2. Nutrition and Hydration

__________

3. Pain Relief

__________

4. Organ Donation

__________

Witness Attestation

We, the undersigned witnesses, each being at least eighteen (18) years of age, declare that __________ signed this document in our presence, appeared to be of sound mind and under no duress, and that we signed as witnesses in the presence of __________ and of each other. Neither of us is a beneficiary under this document.

Witness 1 Name and Address: ____________________________________________

Witness 2 Name and Address: ____________________________________________