STATUTORY DECLARATION IN CONFORMANCE WITH KANSAS NATURAL DEATH

ACT, KANSAS STATUTES Section 65-28,103

DECLARATION OF ___________________

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, do hereby declare:

If at any time I should have an incurable injury,

disease, or illness certified to be a terminal condition by

two physicians who have personally examined me, one of whom

shall be my attending physician, and the physicians have

determined that my death will occur whether or not life-

sustaining procedures are utilized and where the application

of life-sustaining 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withheld or withdrawn, and that I be permitted to die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 administration of medication 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 life-sustaining procedures, it is

my intention that this declaration shall be honored by my

family and physicians as the final expression of my legal right

to refuse medical or surgical treatment and accept the

consequences from such refusal.

I understand the full import of this declaration and

I am emotionally and mentally competent to make this

declaration.

________________________________________

City of residence: _________________

County of residence: _______________

State of residence: ________________

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 declaration of

the declarant. I am not related to the declarant by blood

or marriage, entitled to any portion of the estate of the

declarant according to the laws of intestate succession or

under any will of declarant or codicil thereto, or directly

financially responsible for declarant's medical care.

Witness _________________________________________________

Witness _________________________________________________

Date: _______________