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withheld or withdrawn, and that I be permitted to die 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: _______________