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#5620
@001 Please state the declarant's name:
@002 Please state the state where signed:
@003 Please state the county were signed:
#end control section
#5620
/* New Hampshire Living Will Para. 4100*/
STATUTORY DECLARATION IN CONFORMANCE WITH NEW HAMPHSIRE TERMINAL
CARE DOCUMENT LAW, N.H. R.S. 137-H: 3
DECLARATION OF @001
Declaration made this __________ day of ________________
19________. I @001, being of sound mind, willfully and
voluntarily make known my desires that my dying shall not be
artificially prolonged under the circumstances set forth below,
do hereby declare:
If at any time I should have an incurable injury,
disease, or illness certified to be a terminal condition by
two physicians who have personally examined me, one of whom
shall be my attending physician, and the physicians have
determined that my death will occur whether or not life-
sustaining procedures are utilized and where the application
of life-sustaining 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withheld or withdrawn, and that I be permitted to die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, sustenance,
or the performance of any medical procedure deemed necessary to
provide me with comfort care.
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 physicians as the final expression of my legal right
to refuse medical or surgical treatment and accept the
consequences from such refusal.
I understand the full import of this declaration and
I am emotionally and mentally competent to make this
declaration.
_______________________________________
Signature- @001
State of @002
@003 County
We, the declarant and the witnesses, being duly sworn
each declare to the notary public or justice of the peace or
other official signing below as follows:
1. The declarant signed the instrument as a free and voluntary
act for the purposes expressed, or expressly directed another
to sign for him.
2. Each witness signed at the request of the declarant, in his
presence, and in the presence of the other witness.
3. To the best of my knowledge at the time of the signing the
declarant was at least 18 years of age, and was of sane mind
and under no constraint or undue influence.
______________________________________________
Declarant
________________________________________________
Witness
________________________________________________
Witness
Sworn to and signed before me by @001 declarant, and ___________
________________ witnesses on _____________________, 199____.
___________________________________________________
Signature
Official Capacity: _____________________