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5610.ARM
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1991-06-27
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114 lines
/* North Carolina form*/
DECLARATION OF A DESIRE FOR A NATURAL DEATH AS PROVIDED
BY NORTH CAROLINA G.S. 90-321
I, @001, being of sound mind, desire that my life not
be prolonged by extraordinary means if my condition is
determined to be terminal and incurable. I am aware and
understand that this writing authorizes a physician to withhold
or discontinue extraordinary means.
This the ______________ day of ___________________ 19______
________________________________________________
SIGNATURE-- @001
I hereby state that the declarant, @001,
being of sound mind signed the above declaration in my presence
and that I am not related to the declarant by blood or marriage
and that I do not know or have a reasonable expectation that
I would be entitled to any portion of the estate of the
declarant, under any existing will or codicil of the declarant,
or as an heir under the Intestate Succession Act if the
declarant died on this date without a will. I also state that I
am not the declarant's attending physician or an employee of
the declarant's attending physician or an employee of a health
facility in which the declarant is a patient or an employee of a
nursing home or any group-care home where the declarant resides.
I further state that I do not now have any claim against the
declarant.
Witness
____________________________________________________________
Witness
____________________________________________________________
Certificate
I, _____________________________________________(state if Clerk
of Superior Court or Deputy Clerk or Notary Public) for
_________________________________ County, hereby certify that
@001, the declarant, appeared before me and swore to me and to
the witnesses in my presence that this instrument is his
Declaration Of A Desire for A Natural Death, and that he
willingly and voluntarily made and executed it as his free act
and deed for the purposes expressed in it, I further certify
that __________________________________ and
__________________________ witnesses, appeared before me and
swore that they witnessed @001, declarant, sign the attached
declaration, believing him to be of a sound mind; and also swore
that at the time they witnessed the declaration (i) they were not
related within the third degree to the declarant or to the
declarant's spouse, and (ii) they did not know or have a
reasonable expectation that they would be entitled to any
portion of the estate of the declarant upon the declarant's death
under any will of the declarant or codicil thereto then existing
or under the Intestate Succession Act as it provides at that
time, and (iii) they were not a physician attending the declarant
or an employee of an attending physician or an employee of a
health facility in which the declarant was a patient or an
employee of a nursing home or any group-care home in which the
declarant resided, and (iv) they did not have a claim against the
declarant. I further certify that I am satisfied as to the
genuineness and due execution of the declaration. This the _____
_____ of ______________, 19______.
________________________________________________
Title: ____________________________________
County of @002