DECLARATION PROVIDED BY MAINE REVISED STATUTES TITLE 22 SECTION

2922

DECLARATION

If I should have an incurable or irreversible condition

that will cause my death within a short time, and if I am unable

to participate in decisions regarding my medical treatment, I

direct my attending physician to withhold or withdraw procedures

that merely prolong the dying process and are not necessary to

my comfort or freedom from pain.

Signed this _____________ day of _______________________________

date month year

Signature ______________________________________________

The declarant is known to me and voluntarily signed this document

in my presence.

Witness ________________________________________________

Address:

Witness ________________________________________________

Address: