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: