DIRECTIVE TO PHYSICIANS AS PROVIDED BY CALIFORNIA HEALTH AND
SAFETY CODE SECTION 7187 


                     DIRECTIVE TO PHYSICIANS 


Directive made this _________________ day of ___________.  
I, __________________, being of sound mind, willfully and
voluntarily make known my desire that my life shall not be
artificially prolonged under the circumstances set forth below, 
do hereby declare: 

1. If at any time I should have an incurable injury, disease, 
or illness certified to be a terminal condition by two  
physicians, and where the application of life-sustaining 
procedures would serve only to artificially prolong the moment 
of my death and where my physician determines that my death 
is imminent whether or not life-sustaining procedures are 
utilized, I direct that such procedures be withheld or 
withdrawn, and that I be permitted to die naturally, 

2. In the absence of my ability to give directions regarding 
the use of such life-sustaining procedures, it is my intention 
that this directive shall be honored by my family and  
physician(s) as the final expression of my legal right to refuse 
medical or surgical treatment and accept the consequences from  
such refusal. 

3. If I have been diagnosed as pregnant and that diagnosis is  
known to my physician, this directive shall have no force or  
effect during the course of my pregnancy. 

4. I have been diagnosed and notified at least 14 days ago as 
having a terminal condition by __________________, M.D. whose
address is ___________, __________. 

I understand that if I have not filed in the physicians name and 
address, it shall be presumed that I did not have a terminal  
condition when I made out this directive. 

5. This directive shall have no force and effect five years  
from the date filled in above. 

6. I understand the full import of this directive and I am  
emotionally and mentally competent to make this directive. 



_________________________________________________ 


 The declarant has been personally known to me and 
I believe him or her to be of sound mind. 
                           



Witness       __________________________________________________ 



Witness       __________________________________________________