This is a required section in which the Declarant (the person the Living Will is prepared for) states his/her intention to make a Living Will. Press [Ctrl+F1] for more information.
This is an optional section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn. Press [Ctrl+F1] for more information.
This is an optional section in which the Declarant states what effect should be given to the Living Will if the Declarant is pregnant. Press [Ctrl+F1] for more information.
This is an optional section which allows for additional specific instructions and requests. Press [Ctrl+F1] for more information.
This recommended section provides that the inclusion of an invalid request or instruction does not invalidate the other provisions. Press [Ctrl+F1] for more information.
This required section provides the signature line for the Declarant who must sign in the presence of witnesses. Press [Ctrl+F1] for more information.
This required section provides signature lines for the witnesses in accordance with state law requirements. Press [Ctrl+F1] for more information.
This is a required section in which a public official (such as a Notary Public) acknowledges the signature of the Declarant and the witnesses. Press [Ctrl+F1] for more information.
This required section includes a statement regarding the signing requirements that is required by Alaska law to appear on the document. Press [Ctrl+F1] for more information.
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Living Will
LIW_AK
The Living Will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withhel or withdrawn under certain circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. This section states the Declarant's intentions regarding life-sustaining procedures during terminal and/or coma circumstances. Press [Ctrl+F1] for more information.
WAK01
! Declaration Section (1 of 9)
DECLARATION
[THIS DOCUMENT IS BEING PREPARED FOR !]
If I should have an incurable or irreversible condition that will cause my death within a relatively short time,
! [optional COMA provision] or a permanently unconscious condition,
it is my desire that my life not be prolonged by administration of life-sustaining procedures.
If my condition is terminal and I am unable to participate in decisions regarding my medical treatment,
! [automatically included if COMA checkbox is marked] or if my unconscious condition is permanent,
I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain.
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-sustaining procedures or treatment during terminal and/or coma circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. This section states the Declarant's intentions regarding life-sustaining procedures during terminal and/or coma circumstances. Press [Ctrl+F1] for more information.
Enter an X if you want to have life-sustaining procedures or treatment withheld or withdrawn if you become permanently unconscious. Press [Ctrl+F1] for more information.
WAK02
! Optional Nutrition Section (2 of 9)
! DO
! DO NOT
desire that nutrition or hydration (food and water) be provided by gastric tube or intravenously if necessary.
Enter an X to include a sentence that states whether you desire or do not desire to have artificial nutrition and hydration provided to you if you are terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if you DO WANT artificially administered nutrition and hydration, even though your physicians certify that you have a terminal or permanently unconscious condition.
Enter an X if you DO NOT WANT artificially administered nutrition and hydration if your physicians certify that you have a terminal or permanently unconscious condition.
LAL04
! Optional Pregnancy Section (3 of 9)
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! [Optional additional sentence] However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
Enter an X to include a pregnancy section which states that this Living Will will not be enforced if you are pregnant. Certain exceptions to this statement are presented. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception permits enforcement of the Living Will if the fetus could not develop to the point of live birth with the continued application of life-sustaining procedures.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception requests that pain or physical harm to you be considered in determining whether life-sustaining procedures or treatment should be withheld or withdrawn.
LAL05
! Optional Other Specific Requests Section (4 of 9)
Other specific requests:
Enter an X to include a paragraph that allows you to state other specific requests or instructions.
Use this space to state any other specific requests or instructions.
LAL06
! Optional Severability Section (5 of 9)
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
It is recommended that this severability provision be included to prevent one invalid provision from invalidating the entire document. However, if you do not want to include it, press the spacebar to deselect the checkbox. Press [Ctrl+F1] for information regarding the reasons for including a severability paragraph.
WAK06
! Declarant Signature Section (6 of 9)
Date Signed: _______________ _____, 19___.
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
County: ! County
State: !
! Country: !
! SSN: !
! Birthdate: !
This required section provides a signature line for the Declarant, and requests additional information regarding the Declarant. The date of the document should be entered on the blank lines at the time the document is signed. Press [Enter] to go to the first entry field.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's county/parish or edit the information as desired.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the country in which the Declarant resides, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By providing the SSN, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Enter the Declarant's social security number or edit the information as desired.
Enter an X to include the Declarant's date of birth. By providing the date of birth, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the Declarant's date of birth or edit the information as desired.
WAK07
! Witness Signature Section (7 of 9)
[CAREFULLY REVIEW THE RESTRICTIONS ON WHO MAY BE A WITNESS. IF THE DOCUMENT IS NOT PROPERLY WITNESSED, IT MAY NOT BE ENFORCEABLE.]
The Declarant is known to me and voluntarily signed or voluntarily directed another to sign this document in my presence. I am at least 18 years old and am not related to the Declarant by blood or marriage.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses. The date of the document should be entered on the blank lines at the time the document is signed.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
WAK08
! Acknowledgement Section (8 of 9)
State of Alaska, _________________________ Judicial District:
The foregoing instrument was acknowledged before me this _____ day of _______________, 19___, by !.
_________________________________________
Signature of Person Taking Acknowledgment
_________________________________________
Title or Rank
_________________________________________
Serial Number, if any
This is a required section in which a person, such as a Notary Public, acknowledges that the witnesses and the Declarant signed this document.
WAK09
! Code Reference Section (9 of 9)
THIS DECLARATION MUST BE EITHER WITNESSED BY TWO PERSONS OR ACKNOWLEDGED BY A PERSON QUALIFIED TO TAKE ACKNOWLEDGEMENTS UNDER ALASKA STATUTES 09.63.010.
This required section includes a statement regarding the signing requirements that are required by Alaska law to appear on this document.
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