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5008.BLD
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1993-01-06
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#5008
@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
#5008
/* Georgia living will */
LIVING WILL AS PROVIDED BY GEORGIA CODE SECTION
31-32-3
LIVING WILL
Living will made this _________________ day of ___________. I
@001, being of sound mind, willfully and
voluntarily make known my desire that my life shall not be
prolonged under the circumstances set forth below, and do
declare:
1. If at any time I should have a terminal condition as defined
and established in accordance with the procedures set forth
in paragraph 10 of Code Section 31-32-2 of the Official Code of
Georgia, I direct that the application of life-sustaining
procedures to my body be withheld or withdrawn and that I be
permitted to die;
2. In the absence of my ability to give directions regarding
the use of such life-sustaining procedures, it is my intention
that this living will shall be honored by my family and
physician(s) as the final expression of my legal right to refuse
medical or surgical treatment and accept the consequences from
such refusal;
3. I understand that I may revoke this living will at any time;
4. I understand the full import of this directive and I am
emotionally and mentally competent to make this living will; and
5. If I am female and I have been diagnosed as pregnant, this
living will shall have no force or effect during the course of my
pregnancy.
Signed _________________________________________________
@001
City of residence: @002
County of residence: @003
State of residence: @004
I hereby witness this living will and attest that:
1. The declarant is personally known to me and I believe the
declarant to be at least 18 years of age and of sound mind;
2. I am at least 18 years of age;
3. To the best of my knowledge, at the time of the execution of
this living will, I:
A) Am not related to the declarant by blood or marriage;
B) Would not be entitled to any portion of the declarant's
estate by any will or by operation of law under the
rules of descent and distribution of this state;
C) Am not the attending physician of declarant or an
employee of the hospital or skilled nursing facility
in which the declarant is a patient;
D) Am not directly financially responsible for the
declarant's medical care; and
E) Have no present claim against any portion of the
estate of the declarant;
4. Declarant has signed this document in my presence as above-
instructed, on the date above first shown.
Witness:
_____________________________________________________
Address:
Witness:
____________________________________________________
Address: