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5580.BLD
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1992-08-31
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#5580
@001 Please state the name of the declarant:
@002 Please state the city where signed:
@003 Please state the county where signed:
@004 Please state the state where signed:
#end control section
#5580
/* Missouri living will*/
DECLARATION IN CONFORMANCE WITH MISSOURI STATUTES 459.015
I have the primary right to make my own decisions
concerning treatment that might unduly prolong the dying
process. By this declaration I express to my physician,
family and friends my intent. If I should have a terminal
condition it is my desire that my dying not be prolonged by
administration of death-prolonging procedures. If my condition
is terminal and I am unable to participate in decisions regarding
my medical treatment, I direct that my attending physician to
withhold or withdraw medical procedures that merely prolong the
dying process and are not necessary to my comfort or to
alleviate pain. It is not my intent to authorize affirmative or
deliberate acts or omissions to shorten my life rather only
to permit the natural process of dying.
Signed this ____________________ day of ________________
____________________.
________________________________________________________________
Signature- @001
City of residence: @002
County of residence: @003
State of residence: @004
The declarant is known to me, is eighteen years of age
or older, of sound mind and voluntarily signed this document
in my presence.
________________________________________________________________
Witness
Address:
________________________________________________________________
Witness
Address: