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5830.BLD
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1993-01-06
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#5830
@001 Please state the name of the declarant:
@002 Please state the street address of declarant:
@003 Please state the city, state of declarant:
#end control section
#5830
/*West Virginia Living Will Para.
STATUTORY DECLARATION IN CONFORMANCE WITH WEST VIRGINIA
NATURAL DEATH ACT, 16-30-3
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 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
is 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withheld or withdrawn, and that I be permitted to die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 nutrition, medication
or the performance of any medical procedure deemed necessary to
provide me with 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 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
Address: @002
@003
I did not sign the declarant's signature above for
or at the direction of the declarant. I am at least eighteen
years of age and am not related to the declarant by blood or
marriage, entitled to any portion of the estate of the declarant
according to the laws of intestate succession of the State of
West Virginia, or to the best of my knowledge under any will of
declarant or codicil thereto, or directly financially responsible
for declarant's medical care. I am not the declarant's attending
physician, an employee of the attending physician, nor an
employee of the health facility in which the declarant is a
patient.
________________________________________________
Witness
________________________________________________
Witness
STATE OF ________________________
COUNTY OF _______________________
This day personally appeared before me, the undersigned
authority, a Notary Public in and for ______________ County,
___________________________State, ______________________________
_______________________________(Witnesses) who, being first being
duly sworn, say that they are the subscribing witnesses to the
declaration of @001, the declarant, signed, sealed and
published and declared the same as and for his declaration, in
the presence of both these affiants; and that these affiants, at
the request of said declarant, in the presence of each other, and
in the presence of said declarant, all present at the same time,
signed their names as attesting witnesses to said declaration.
Affiants further say that this affidavit is made at the
request of @001, declarant, and in his presence, and that @001
at the time the declaration was executed, in the opinion of the
affiants, of sound mind and memory, and over the age of eighteen
years.
Taken, subscribed and sworn to before me by ____________
___________ (witness) and ____________________________ (witness)
this _______ day of __________________________________, 19_____.
My commission expires: __________________
___________________________________
Notary Public