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5560.BLD
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1993-01-06
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#5560
@001 Please state the name of the declarant:
@002 Please state street address of declarant:
@003 Please state city, state address of declarant:
#end control section
#5560
/* Maryland Living Will*/
DECLARATION AS PROVIDED BY MARYLAND HEALTH-GENERAL
CODE SECTION 5-602
DECLARATION
On this _________________ day of ___________, I
@001, being of sound mind, willfully and voluntarily direct that
my dying shall not be artificially prolonged under the
circumstances set forth in this declaration:
If at any time I should have an incurable injury, disease,
or illness certified to be a terminal condition by two (2)
physicians who have personally examined me, one (1) of whom
shall be my attending physician, and the physicians have
determined that my death is imminent whether or not life-
sustaining procedures are utilized and where the application of
such procedures would serve only to artificially prolong the
dying process, I direct that such procedures be withheld or
withdrawn, and that I be permitted to die naturally with only
the administration of medication, and the administration of
food and water, and the performance of any medical procedure
that is necessary to provide comfort care or to alleviate pain.
In the absence of my ability to give directions regarding the
use of such life-sustaining procedures, it is my intention that
this declaration shall be honored by my family and physician(s)
as the final expression of my legal right to control my medical
care or treatment. I am legally competent to make this
declaration, and I understand its full import.
Signed _________________________________________________________
@001
Address: @002
@003
Under penalty of perjury, we state that this declaration was
signed by @001 in the presence of the undersigned who, at @001's
request, in @001's presence, and in the presence of each other,
have hereunto signed our names as witnesses this _______________
day of ___________________ 19_______. Further, each of us,
individually, states that:
The declarant is known to me, and I believe the declarant to be
of sound mind. I did not sign the declarant's signature to this
declaration. Based upon information and belief, I am not related
to the declarant by blood or marriage, a creditor of the
declarant, entitled to any portion of the estate of the declarant
under any existing testamentary instrument of the declarant,
entitled to any financial benefit by reason of the death of the
declarant, financially or otherwise responsible for the
declarant's medical care, nor the employee of any such person or
institution.
________________________________________________
Address:
________________________________________________
Address: