DECLARATION AS PROVIDED BY MONTANA STATS. 50-9-104 

   DECLARATION 


 If I should have an incurable or irreversible condition that will
cause my death within a reasonable short time, it is my desire
that my life not be prolonged by administration of life-sustaining
procedures. If my condition is terminal and 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. It is my intention that this
declaration shall be valid until revoked by me. 

Signed this ___________________ day of ______________ 




________________________________________________________________ 
Signature - ______________

City of residence: __________________
County of residence: ________________
State of residence: _________________


 The declarant is known to me and voluntarily signed this 
document in my presence. 


Witness: 


_____________________________________________________________ 



Witness: 




_____________________________________________________________