STATUTORY DECLARATION IN CONFORMANCE WITH WYOMING LIVING WILL LAW,

WYOMING STATUTES 35-22-102

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

hereby 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 shall be 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procedures be withheld or withdrawn, and that I be permitted to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 medication or the

performance of any medical procedure deemed necessary to provide

me with comfort care.

If, in spite of this declaration, I am comatose or otherwise

unable to make treatment decisions for myself, I HEREBY designate

______________ to make treatment decisions for me.

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.

________________________________________

City of residence: ____________

County of residence: __________

State of Residence: ___________

Date: _______________________________________

The declarant has been personally known to me and I believe him

or her to be of sound mind. I did not sign the declarant's

signature above for or at the declaration of the declarant. I 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 or under any will of declarant or codicil

thereto, or directly financially responsible for declarant's

medical care.

Witness _____________________________________________

Witness _____________________________________________

Date: _____________________