LIVING WILL AS PROVIDED BY TENNESSEE CODE 32-11-105

LIVING WILL OF ___________________

I, ____________, willfully and voluntarily make known my desires

that my dying shall not be artificially prolonged under the

circumstances set forth below, and do hereby declare:

If at any time I should have a terminal condition and my

attending physician has determined that there can be no recovery

from such condition and my death is imminent, and where the

application of life-prolonging procedures would serve only to

artificially prolong the dying process, I direct that such

procedures be withheld or withdrawn, and that I be permitted to

die naturally with only the administration of medications or the

performance of any medical procedure deemed necessary to provide

me with comfort care or to alleviate pain.

In the absence of my ability to give directions regarding the use

of such life-sustaining procedures, it is my intention that this

declaration shall be honored by my family and physicians as the

final expression of my legal right to refuse medical or surgical

treatment and accept the consequences from such refusal.

I understand the full import of this declaration and I am

emotionally and mentally competent to make this declaration. In

acknowledgement whereof, I do hereinafter

affix my signature on this the ___________ day of ______________

19___________.

_____________________________________________________________

Declarant- ________________

Residing at : _____________

___________________________

We, the subscribing witnesses hereto, are personally acquainted

with and subscribe our names hereto at the request of the

declarant, an adult, whom we believe to be of sound mind, fully

aware of the action taken herein and its possible consequence. We,

the undersigned witnesses, further declare that we are not related

to the declarant by blood or marriage; that we are not entitled to

any portion of the estate of the declarant upon his decease under

any will or codicil thereto presently existing or by operation of

law then existing; that we are not the attending physician, an

employee of the attending physician or a health facility in which

the declarant is a patient; and that we are not a person who, at

the present time, has a claim against any portion of the estate of

the declarant upon his death.

Witness ______________________________________________

Witness _______________________________________________

Subscribed, sworn to and acknowledged before me by ____________,

the declarant, and subscribed to before me

by __________________________ and _____________________________,

witnesses, this _______ day of ___________________________ 19___.

_______________________________________________________________

Notary Public