STATUTORY DECLARATION IN CONFORMANCE WITH INDIANA LIVING WILL AND

LIFE-PROLONGING PROCEDURES ACT, INDIANA CODE 16-8-11-12

LIVING WILL DECLARATION OF ________________

Declaration made this __________ day of

_________________ 19________. I, _____________, being at least

eighteen (18) years old and of sound mind, willfully and

voluntarily make known my desires that my dying shall not be

artificially prolonged under the circumstances set forth below,

and I declare:

If at any time I should have an incurable and irreversible

injury, disease, or illness certified in writing to be a terminal

condition by my attending physician, and my attending physician

has determined that my death will occur in a short period of time,

and the use of life-prolonging procedures would serve only to

artificially prolong the dying process, I direct that such

procedures be withheld or withdrawn, and that I be permitted to

die naturally with only the provision of appropriate nutrition and

hydration and the administration of medication and 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 prolonging 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 of the refusal.

I understand the full import of 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. I did not sign the declarant's

signature above for or at the direction of the declarant. I am not

a parent, spouse, or child of the declarant. I am not entitled to

any part of the declarant's estate or directly financially

responsible for declarant's medical care. I am competent and at

least eighteen (18) years old.

Witness _________________________________________________

Witness _________________________________________________

Date: _______________________