DECLARATION AS PROVIDED BY IOWA CODE 144A.3 
           DECLARATION OF __________________


 If I should have an incurable or irreversible condition 
that will cause my death within a relatively short time, it is 
my desire that my life not be prolonged by administration of 
life-sustaining procedures. If my condition is terminal and I 
am unable to participate in decisions regarding my medical 
treatment, I direct my attending physician to withhold or 
withdraw procedures that merely prolong the dying process and 
are not necessary to my comfort or freedom from pain. 
Signed this _______________ day of _______________, 19_____ 
Signature: 


________________________________________________________________ 
 The declarant is known to me and voluntarily signed this 
document in my presence. 
Witness: 


________________________________________________________________ 
Address: 


Witness: 


________________________________________________________________ 
Address: