DECLARATION IN CONFORMANCE WITH MISSOURI STATUTES 459.015

I have the primary right to make my own decisions concerning

treatment that might unduly prolong the dying process. By this

declaration I express to my physician, family and friends my

intent. If I should have a terminal condition it is my desire that

my dying not be prolonged by administration of death-prolonging

procedures. If my condition is terminal and I am unable to

participate in decisions regarding my medical treatment, I direct

that my attending physician to withhold or withdraw medical

procedures that merely prolong the dying process and are not

necessary to my comfort or to alleviate pain. It is not my intent

to authorize affirmative or deliberate acts or omissions to

shorten my life rather only to permit the natural process of

dying.

Signed this ____________________ day of ________________

____________________.

________________________________________________________________

Signature- __________________

City of residence: __________

County of residence: ________

State of residence: _________

The declarant is known to me, is eighteen years of age or older,

of sound mind and voluntarily signed this document in my presence.

________________________________________________________________

Witness

Address:

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Witness

Address: