STATUTORY DECLARATION IN CONFORMANCE WITH WEST VIRGINIA NATURAL

DEATH ACT, 16-30-3

DECLARATION OF _________________

Declaration made this __________ day of ________________

19______. I, __________________, being of sound mind, willfully

and voluntarily make known my desires that my dying shall not be

artificially prolonged under the circumstances set forth below,

do declare:

If at any time I should have an incurable injury, disease, or

illness certified to be a terminal condition by two physicians who

have personally examined me, one of whom is my attending

physician, and the physicians have determined that my death will

occur whether or not life- sustaining procedures are utilized and

where the application of life-sustaining 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procedures be withheld or withdrawn, and that I be permitted to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 nutrition,

medication 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.

________________________________________

Signature- _____________________

Address: _______________________

_______________________

I did not sign the declarant's signature above for or at the

direction of the declarant. I am at least eighteen years of age

and am not related to the declarant by blood or marriage,

entitled to any portion of the estate of the declarant according

to the laws of intestate succession of the State of West

Virginia, or to the best of my knowledge under any will of

declarant or codicil thereto, or directly financially responsible

for declarant's medical care. I am not the declarant's attending

physician, an employee of the attending physician, nor an

employee of the health facility in which the declarant is a

patient.

________________________________________________

Witness

________________________________________________

Witness

STATE OF ________________________

COUNTY OF _______________________

This day personally appeared before me, the undersigned

authority, a Notary Public in and for ______________ County,

___________________________State, ______________________________

_______________________________(Witnesses) who, being first being

duly sworn, say that they are the subscribing witnesses to the

declaration of ________________, the declarant, signed, sealed

and published and declared the same as and for his declaration,

in the presence of both these affiants; and that these affiants,

at the request of said declarant, in the presence of each other,

and in the presence of said declarant, all present at the same

time, signed their names as attesting witnesses to said

declaration.

Affiants further say that this affidavit is made at the request

of _________________, declarant, and in his presence, and that

________________ at the time the declaration was executed, in the

opinion of the affiants, of sound mind and memory, and over the

age of eighteen years.

Taken, subscribed and sworn to before me by ____________

___________ (witness) and ____________________________ (witness)

this _______ day of __________________________________, 19_____.

My commission expires: __________________

___________________________________

Notary Public