DIRECTIVE TO PHYSICIANS AS PROVIDED BY NEVADA REVISED STATUTES,

SECTION 449.610

DIRECTIVE TO PHYSICIANS

Date __________________

I, _______________, being of sound mind, intentionally and

voluntarily declare:

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

illness certified to be a terminal condition by two physicians,

and where the application of life-sustaining procedures would

serve only to artificially prolong the moment of my death and

where my physician determines that my death is imminent whether or

not life-sustaining procedures are utilized, I direct that such

procedures be withheld or withdrawn, and that I be permitted to

die naturally,

2. It is my intention that this directive shall be honored by my

family and attending physician as the final expression of my legal

right to refuse medical or surgical treatment and accept the

consequences from such refusal.

3. If I have been diagnosed as pregnant and that fact is known to

my physician, this directive shall have no force or effect during

the course of my pregnancy. I understand the full import of this

directive and I am emotionally and mentally competent to execute

it.

Signed _________________________________________________

STATE OF _______)))

COUNTY OF __________)))

Dated: _________________________

Then and there personally appeared the within named

________________________________ and __________________________ ,

who, being duly sworn, depose and say: That they witnessed the

execution of the within Directive to Physicians of the within

named _______________, that said declarant subscribed said

Directive to Physicians and declared the same to be his Directive

to Physicians in their presence, that they thereafter subscribed

the same as witnesses in the presence of said declarant and in the

presence of each other and at the request of said Declarant; that

the said Declarant at the time of the execution of said Directive

to Physicians appeared to them to be of full age and of sound mind

and memory, and that they make this affidavit at the request of

said declarant.

________________________________________

Witness

________________________________________

Witness

Subscribed to and sworn to before me

this ________ day of _________, 19_____.

_____________________________________________

Notary Public