DECLARATION OF INTENTION PROVIDED BY MISSISSIPPI WITHDRAWAL OF LIFE

SAVING MECHANISMS ACT, MISSISSIPPI CODE 41-41-107

DECLARATION made on ___________ by ___________________

of ____________, _______________,

I, ________________, being of sound mind, declare that if

at any time I should suffer a terminal physical condition which

causes me severe distress or unconsciousness, and my physician,

with the concurrence of two (2) other physicians, believes that

there is no expectation of my regaining consciousness or a state

of health that is meaningful to me and but for the use of

life-sustaining mechanisms my death would be imminent, I desire

that the mechanisms be withdrawn so that I may die naturally.

However, if I have been diagnosed as pregnant and that diagnosis

is known to my physician, this declaration shall have no force or

effect during the course of my pregnancy. I further declare that

this declaration shall be honored by my family and my physician

as the final expression of my desires concerning the manner in

which I die.

SIGNED:

________________________________________________________________

Social Security number: ___________

I hereby witness this declaration and attest that:

(1) I personally know the declarant and believe the

Declarant to be of sound mind.

(2) To the best of my knowledge, at the time of the

execution of this declaration, I:

(a) Am not related to the Declarant by blood or marriage,

(b) Do not have any claim on the estate of the Declarant,

(c) Am not entitled to any portion of the Declarant's

estate by any will or operation of law, and

(d) Am not a physician attending the declarant or a

person employed by a physician attending the declarant.

WITNESS:

________________________________________________________________

Address:

WITNESS:

________________________________________________________________

Address: