DECLARATION OF A DESIRE FOR A NATURAL DEATH AS PROVIDED BY NORTH

CAROLINA G.S. 90-321

I, ________________, being of sound mind, desire that my

life not be prolonged by extraordinary means if my condition is

determined to be terminal and incurable. I am aware and understand

that this writing authorizes a physician to withhold or

discontinue extraordinary means.

This the ______________ day of ___________________ 19______

________________________________________________

SIGNATURE-- _________________

I hereby state that the declarant, ________________,

being of sound mind signed the above declaration in my presence

and that I am not related to the declarant by blood or marriage

and that I do not know or have a reasonable expectation that I

would be entitled to any portion of the estate of the declarant,

under any existing will or codicil of the declarant, or as an

heir under the Intestate Succession Act if the declarant died on

this date without a will. I also state that I am not the

declarant's attending physician or an employee of the declarant's

attending physician or an employee of a health facility in which

the declarant is a patient or an employee of a nursing home or

any group-care home where the declarant resides. I further state

that I do not now have any claim against the declarant.

Witness

____________________________________________________________

Witness

____________________________________________________________

Certificate

I, _____________________________________________(state if Clerk

of Superior Court or Deputy Clerk or Notary Public) for

_________________________________ County, hereby certify that

________________, the declarant, appeared before me and swore to

me and to the witnesses in my presence that this instrument is his

Declaration Of A Desire for A Natural Death, and that he willingly

and voluntarily made and executed it as his free act and deed for

the purposes expressed in it, I further certify

that __________________________________ and

__________________________ witnesses, appeared before me and swore

that they witnessed ________________, declarant, sign the

attached declaration, believing him to be of a sound mind; and

also swore that at the time they witnessed the declaration (i)

they were not elated within the third degree to the declarant or

to the declarant's spouse, and (ii) they did not know or have a

reasonable expectation that they would be entitled to any portion

of the estate of the declarant upon the declarant's death under

any will of the declarant or codicil thereto then existing or

under the Intestate Succession Act as it provides at that time,

and (iii) they were not a physician attending the declarant or an

employee of an attending physician or an employee of a health

facility in which the declarant was a patient or an employee of a

nursing home or any group-care home in which the declarant

resided, and (iv) they did not have a claim against the declarant.

I further certify that I am satisfied as to the

genuineness and due execution of the declaration. This the _____

_____ of ______________, 19______.

________________________________________________

Title: ____________________________________

County of _____________