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1992-08-31
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#5840
@001 Please state the name of the declarant:
@002 Please state the state where signed:
@003 Please state the county where signed:
#end control section
#5840
/*Nevada Living Will Form, Para. 4440 */
DIRECTIVE TO PHYSICIANS AS PROVIDED BY NEVADA REVISED
STATUTES, SECTION 449.610
DIRECTIVE TO PHYSICIANS
Date __________________
I, @001, being of sound mind, intentionally and voluntarily
declare:
1. If at any time I should have an incurable injury, disease,
or illness certified to be a terminal condition by two
physicians, and where the application of life-sustaining
procedures would serve only to artificially prolong the moment
of my death and where my physician determines that my death
is imminent whether or not life-sustaining procedures are
utilized, I direct that such procedures be withheld or
withdrawn, and that I be permitted to die naturally,
2. It is my intention that this directive shall be honored
by my family and attending physician as the final expression
of my legal right to refuse medical or surgical treatment
and accept the consequences from such refusal.
3. If I have been diagnosed as pregnant and that fact is
known to my physician, this directive shall have no force or
effect during the course of my pregnancy. I understand the full
import of this directive and I am emotionally and mentally
competent to execute it.
Signed _________________________________________________
@001
STATE OF @002))))
COUNTY OF @003))) ss.
Dated: _________________________
Then and there personally appeared the within named
________________________________ and __________________________ ,
who, being duly sworn, depose and say: That they witnessed the
execution of the within Directive to Physicians of the within
named @001, that said declarant subscribed said Directive to
Physicians and declared the same to be his Directive to
Physicians in their presence, that they thereafter subscribed
the same as witnesses in the presence of said declarant
and in the presence of each other and at the request of said
Declarant; that the said Declarant at the time of the execution
of said Directive to Physicians appeared to them to be of full
age and of sound mind and memory, and that they make this
affidavit at the request of said declarant.
________________________________________
Witness
________________________________________
Witness
Subscribed to and sworn to before me
this ________ day of _________, 19_____.
_____________________________________________
Notary Public