STATUTORY DECLARATION IN CONFORMANCE WITH ILLINOIS NATURAL DEATH

ACT, IL. STAT. 110 1/2 PARAGRAPH 703

DECLARATION OF ______________________

This declaration is made this __________ day of __________

19___________. I _____________________________, being of sound

mind, willfully and voluntarily make known my desires that my

moment of death shall not be artificially postponed.

If at any time I should have an incurable and irreversible

injury, disease, or illness judged to be a terminal condition by

my attending physicians who has personally examined me, and has

determined that my death is imminent except for death delaying

procedures, I direct that such procedures which would serve only

to prolong the dying process be withheld or withdrawn, and that I

be permitted to die naturally with only the administration of

medication, sustenance, or the performance of any medical

procedure deemed necessary to provide me with comfort care.

In the absence of my ability to give directions regarding the use

of such death delaying procedures, it is my intention that this

declaration shall be honored by my family and physician as the

final expression of my legal right to refuse medical or surgical

treatment and accept the consequences from such refusal.

________________________________________

City of Residence: ________________

County of Residence: ______________

State of Residence: _______________

Date: __________________________________

Witness _________________________________________________

Witness _________________________________________________

Date: ___________________________________