DECLARATION AS PROVIDED BY HAWAII REVISED STATUTES CHAPTER 327D

SECTION 4

DECLARATION

A. Statement of Declarant

Declaration made this __________________ day of

_____________, 19_______. I, _________________ being of sound

mind, willfully and voluntarily make known my desire that my

dying shall not be artificially prolonged under the circumstances

set forth below, and do hereby declare:

If at any time I should have an incurable or

irreversible condition certified to be terminal by two physicians

who have personally examined me, one of whom shall be my

attending physician, and the physicians have determined that I am

unable to make decisions concerning my medical treatment, and

that without administration of life-sustaining treatment my death

will occur in a relatively short time, and where the application

of life-sustaining procedures would serve only to prolong

artificially 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withheld or withdrawn, and that I be permitted to die naturally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, nourishment, or

fluids or the performance of any medical procedure deemed

necessary to provide me with comfort or to alleviate pain.

I understand the full import of this declaration

and I am emotionally and mentally competent to make this

declaration.

Signed:

________________________________________________________________

STATE OF ____________________

COUNTY OF ___________________

B. Statement of Witnesses

I am at least 18 years of age and

-not related to the declarant by blood, marriage or adoption; and

-not the attending physician, an employee of the attending

physician, or an employee of the medical care facility in which

the declarant is a patient.

The declarant is personally known to me and I

believe the declarant to be of sound mind.

Witness:

_______________________________________________________________

Address:

Witness:

_______________________________________________________________

Address:

C) Notarization

Subscribed, sworn to and acknowledged before me by

_________________, the declarant, and subscribed and sworn to

before me by

___________________ and ___________________, witnesses, this

______________ day of ________________________, 19_______.

_____________________________________

Official Capacity: _________________