STATUTORY DECLARATION IN CONFORMANCE WITH ARIZONA MEDICAL

TREATMENT DECISION ACT, AZ. REV. STAT. 36-3202

DECLARATION OF __________________

Declaration made this __________ day of ________________

19________. I, ______________, being of sound mind, willfully and

artificially prolonged under the circumstances set forth below

and declare that:

If at any time I should have an incurable injury,

disease, or illness certified to be a terminal condition by

two physicians who have personally examined me, one of whom

is my attending physician, and the physicians have determined

that my death will occur unless life-sustaining procedures are

used and if the application of life-sustaining procedures would

serve only to artificially prolong the dying process, I direct

that such procedures be withheld or withdrawn, and that I be

permitted to die naturally with only the administration of

medication, food or fluids or the performance of any medical

procedures deemed necessary to provide me with comfort care.

In the absence of my ability to give directions

regarding the use of such life-sustaining procedures, it is

my intention that this declaration shall be honored by my

family and physicians as the final expression of my legal right

to refuse medical or surgical treatment and accept the

consequences from such refusal.

I understand the full import of this declaration and

I have the emotionally and mental capacity to make this

declaration.

________________________________________

City of residence: _____________

County of residence: ___________

State of residence: ____________

Date: ________________________________

The declarant has been personally known to me and

I believe him or her to be of sound mind.

Witness _________________________________________________

Witness _________________________________________________

Date: _________________________