STATUTORY DECLARATION IN CONFORMANCE WITH FLORIDA LIFE PROLONGING

PROCEDURE ACT, F.S. 765.05

DECLARATION OF ________________________

Declaration made this __________ day of _____________

19________. I ___________ willfully and voluntarily

make known my desire that my dying shall not be artificially

prolonged under the circumstances set forth below, do hereby

declare:

If at any time I should have a terminal condition,

and if my attending physician has determined that there can

be no recovery from such condition and my death is imminent,

I direct that such procedures be withheld or withdrawn, and

that I be permitted to die naturally with only the

administration of medication or the performance of any medical

procedure deemed necessary to provide me with comfort care or

to alleviate pain.

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 for such refusal.

If I have been diagnosed as pregnant and that

diagnosis is known to my physician, this declaration shall have

no force or effect during the course of my pregnancy.

I understand the full import of this declaration and

I am emotionally and mentally competent 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: ___________________________