UNIFORM LIVING WILL

OF ________________________________

To my family, my physician, my lawyer, my clergyman. To any

medical facility in whose care I happen to be. To any individual

who may become responsible for my health, welfare or affairs.

Death is as much a reality as birth, growth, maturity and old age

-- it is the one certainty of life. If the time comes when I,

________________, can no longer take part in decisions of my own

future, let this statement stand as an expression of my wishes

while I am still of sound mind.

If the situation should arise in which I am in terminal state and

there is no reasonable expectation of my recovery, I direct that

I be allowed to die a natural death and that my life not be

prolonged by extraordinary measures. I do, however, ask that

medication be mercifully administered to me to alleviate

suffering even though this may shorten my remaining life.

This statement is made after careful consideration and is in

accordance with my strong convictions and beliefs. I want the

wishes and directions here expressed carried out to the extent

permitted by law. Insofar as they are not legally enforceable, I

hope that those to whom this will is addressed will regard

themselves as morally bound by these provisions.

If it is permissible under the laws of the jurisdiction in which I

may be hospitalized I direct that the physicians supervising my

care upon a terminal diagnosis to discontinue hydration (water)

should the continuation of hydration be judged to result in unduly

prolonging a natural death.

If it is permissible under the laws of the jurisdiction in which I

may be hospitalized I direct that the physicians supervising my

care upon a terminal diagnosis to discontinue feeding should the

continuation of hydration be judged to result in unduly

prolonging a natural death.

I herewith release any and all hospitals, physicians, and others

both for myself and for my estate from any and all liability for

complying with this declaration, to the fullest extent provided by

law.

I herewith authorize my spouse, if any, or any relative who is

related to me within the third degree to effectuate my transfer

from any hospital or other health care facility in which I may be

receiving care should that facility decline or refuse to

effectuate the instructions given herein.

Signed:

_______________________________________________________________

City of residence: _______________

County of residence: _____________

State of residence: ______________

Social Security Number: __________

Date: _________________

________________________________________________________________

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