LIVING WILL AS PROVIDED BY GEORGIA CODE SECTION 31-32-3

LIVING WILL

Living will made this _________________ day of ___________. I

_______________________, being of sound mind, willfully and

voluntarily make known my desire that my life shall not be

prolonged under the circumstances set forth below, and do

declare:

1. If at any time I should have a terminal condition as defined

and established in accordance with the procedures set forth

in paragraph 10 of Code Section 31-32-2 of the Official Code of

Georgia, I direct that the application of life-sustaining

procedures to my body be withheld or withdrawn and that I be

permitted to die;

2. In the absence of my ability to give directions regarding

the use of such life-sustaining procedures, it is my intention

that this living will 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. I understand that I may revoke this living will at any time;

4. I understand the full import of this directive and I am

emotionally and mentally competent to make this living will; and

5. If I am female and I have been diagnosed as pregnant, this

living will shall have no force or effect during the course of my

pregnancy.

Signed _________________________________________________

_________________________

City of residence: _______________

County of residence: _____________

State of residence: ______________

I hereby witness this living will and attest that:

1. The declarant is personally known to me and I believe the

declarant to be at least 18 years of age and of sound mind;

2. I am at least 18 years of age;

3. To the best of my knowledge, at the time of the execution of

this living will, I:

A) Am not related to the declarant by blood or marriage;

B) Would not be entitled to any portion of the declarant's

estate by any will or by operation of law under the

rules of descent and distribution of this state;

C) Am not the attending physician of declarant or an

employee of the hospital or skilled nursing facility

in which the declarant is a patient;

D) Am not directly financially responsible for the

declarant's medical care; and

E) Have no present claim against any portion of the

estate of the declarant;

4. Declarant has signed this document in my presence as above-

instructed, on the date above first shown.

Witness:

_____________________________________________________

Address:

Witness:

____________________________________________________

Address: