LIVING TESTAMENT AS PROVIDED BY CONNECTICUT STATUTES SECTION
19a-575 


                            TESTAMENT 

 If the time comes when I am incapacitated to the 
point where I can no longer actively take part in decisions 
for my own life, and am unable to direct my physician as to 
my own medical care, I wish this statement to stand as a 
testament of my wishes. I _________________ request that I be 
allowed to die and not be kept alive through life support system 
if my condition is deemed terminal. I do not intend any direct 
taking of my life, but only that my dying not be unreasonably 
prolonged.  

This request is made, after careful reflection, while I am of  
sound mind. 









        Signed ______________________________________________ 


Witness       __________________________________________________ 


Witness       __________________________________________________