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1991-06-27
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/* Mississippi Living Will */
DECLARATION OF INTENTION PROVIDED BY MISSISSIPPI
WITHDRAWAL OF LIFE SAVING MECHANISMS ACT, MISSISSIPPI
CODE 41-41-107
DECLARATION made on ___________ by @001
of @002, @003,
I, @001, being of sound mind, declare that if at any
time I should suffer a terminal physical condition which causes
me severe distress or unconsciousness, and my physician, with the
concurrence of two (2) other physicians, believes that there is
no expectation of my regaining consciousness or a state of health
that is meaningful to me and but for the use of life-sustaining
mechanisms my death would be imminent, I desire that the mechan-
isms be withdrawn so that I may die naturally. However, if I have
been diagnosed as pregnant and that diagnosis is known to my
physician, this declaration shall have no force or effect during
the course of my pregnancy. I further declare that this declar-
ation shall be honored by my family and my physician as the final
expression of my desires concerning the manner in which I die.
SIGNED:
________________________________________________________________
@001
Social Security number: @004
I hereby witness this declaration and attest that:
(1) I personally know the declarant and believe the
Declarant to be of sound mind.
(2) To the best of my knowledge, at the time of the
execution of this declaration, I:
(a) Am not related to the Declarant by blood or marriage,
(b) Do not have any claim on the estate of the Declarant,
(c) Am not entitled to any portion of the Declarant's
estate by any will or operation of law, and
(d) Am not a physician attending the declarant or a
person employed by a physician attending the declarant.
WITNESS:
________________________________________________________________
Address:
WITNESS:
________________________________________________________________
Address: