DECLARATION AS PROVIDED BY MARYLAND HEALTH-GENERAL CODE SECTION

5-602

DECLARATION

On this _________________ day of ___________, I ________

______, being of sound mind, willfully and voluntarily direct

that my dying shall not be artificially prolonged under the

circumstances set forth in this declaration:

If at any time I should have an incurable injury, disease, or

illness certified to be a terminal condition by two (2) physicians

who have personally examined me, one (1) of whom shall be my

attending physician, and the physicians have determined that my

death is imminent whether or not life- sustaining procedures are

utilized and where the application of such 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procedures be withheld or withdrawn, and that I be permitted to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, and the

administration of food and water, and the performance of any

medical procedure that is necessary to provide comfort care or to

alleviate pain. 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

physician(s) as the final expression of my legal right to control

my medical care or treatment. I am legally competent to make this

declaration, and I understand its full import.

Signed _________________________________________________________

Address: _______________________________________________________

Under penalty of perjury, we state that this declaration

was signed by ______________ in the presence of the undersigned

who, at ______________'s request, in ______________'s presence,

and in the presence of each other, have hereunto signed our names

as witnesses this _______________ day of ___________________

19_______. Further, each of us, individually, states that:

The declarant is known to me, and I believe the declarant to be

of sound mind. I did not sign the declarant's signature to this

declaration. Based upon information and belief, I am not related

to the declarant by blood or marriage, a creditor of the

declarant, entitled to any portion of the estate of the declarant

under any existing testamentary instrument of the declarant,

entitled to any financial benefit by reason of the death of the

declarant, financially or otherwise responsible for the

declarant's medical care, nor the employee of any such person or

institution.

________________________________________________

Address:

________________________________________________

Address: