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 required section states whether extraordinary measures and/or artificial hydration and nutrition should be withheld if the Declarant is terminal. Press [Ctrl+F1] for more information.
This required section states whether extraordinary measures and/or artificial hydration and nutrition should be withheld. Press [Ctrl+F1] for more information.
This optional section 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 provision 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 and a Notary Public. 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.
Times New Roman
Living Will
LIW_NC
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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
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 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.
WNC01
! Declaration Section (1 of 9)
DECLARATION OF A DESIRE FOR A NATURAL DEATH
I, !, being of sound mind, desire that, as specified below, my life not be prolonged by extraordinary means or by artificial nutrition or hydration, if my condition is determined to be terminal and incurable, or if I am diagnosed as being in a persistent vegetative state. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration, in accordance with my specifications set forth below:
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-sustaining procedures or treatment (extraordinary means) 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. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
WNC02
! Terminal Condition Section (2 of 9)
[This section provides a checklist regarding the Declarant's desires regarding extraordinary means and/or artificial nutrition and hydration if the Declarant becomes TERMINALLY ILL. This checklist must be filled out by the Declarant after the document is printed. Access Document Information for an explanation of this topic.]
(Initial any of the following, as desired):
If my condition is determined to be terminal and incurable, I authorize the following:
________ (initials) My physician may withhold or discontinue extraordinary means only.
________ (initials) In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.
This required section states whether extraordinary means and/or artificial nutrition and hydration should be withheld or withdrawn if you become terminally ill. Press [Ctrl+F1] for more information.
WNC03
! Coma Section (3 of 9)
[This section provides a checklist regarding the Declarant's desires regarding extraordinary means and/or artificial nutrition and hydration if the Declarant is in a PERSISTENT VEGETATIVE STATE (permanently unconscious). This checklist must be filled out by the Declarant after the document is printed. Access Document Information for an explanation of this topic.]
(Initial any of the following as desired):
If my physician determines that I am in a persistent vegetative state, I authorize the following:
________ (initials) My physician may withhold or discontinue extraordinary means only.
________ (initials) In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.
This required section states whether extraordinary means and/or artificial nutrition and hydration should be withheld or withdrawn if you become terminally ill or are in a persistent vegetative state (permanently unconscious). Press [Ctrl+F1] for more information.
WNC04
! Optional Pregnancy Section (4 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 extraordinary means, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If extraordinary means 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 the Declarant is 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 the Declarant is 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 extraordinary means.
Enter an X to provide an exception to the invalidity of the Living Will if the Declarant is pregnant. This exception requests that pain or physical harm to the Declarant be considered in determining whether extraordinary means should be withheld or withdrawn.
LAL05
! Optional Other Specific Requests Section (5 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 (6 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.
WNC07
! Declarant Signature Section (7 of 9)
Dated this ____ day of _______________, 19___.
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
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.
Enter the Declarant's city 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.
WNC08
! Witness Signature Section (8 of 9)
[CAREFULLY REVIEW THE RESTRICTIONS ON WHO MAY BE A WITNESS. IF THE DOCUMENT IS NOT PROPERLY WITNESSED, IT MAY NOT BE ENFORCEABLE.]
I hereby state that the Declarant, !, 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.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses.
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.
WNC09
! Acknowledgement Section (9 of 9)
[This is a required section in which a Notary Public acknowledges that the witnesses and the Declarant signed this document.]
CERTIFICATE
I, __________________________________________________, Notary Public for _________________________ County hereby certify that !, the Declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his/her Declaration Of A Desire For A Natural Death, and that he/she had willingly and voluntarily made and executed it as his/her free act and deed for the purposes expressed in it.
I further certify that ! and !, witnesses appeared before me and swore that they witnessed !, Declarant, sign the attached declaration, believing him/her to be of 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.
Dated this _____ day of _______________, 19___.
________________________________________
NOTARY PUBLIC FOR THE COUNTY OF
________________________________________
This is a required section in which a Notary Public acknowledges that the witnesses and the Declarant signed this document. Press [Ctrl+F1] for more information.
(.txt)