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Complete Home & Office Legal Guide
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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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1993-08-01
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STATUTORY DECLARATION IN CONFORMANCE WITH ALABAMA NATURAL DEATH
ACT, AL.CODE 22-8A-4
DECLARATION OF __________________
Declaration made this __________ day of ________________
19________. I, ______________, 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procedures be withheld or withdrawn, and that I be permitted to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 or the
performance of any medical procedure deemed necessary too 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.
________________________________________
City of residence: _______________
County of residence: _____________
State of residence: ______________
Date: __________________________________
The declarant has been personally known to me and I believe him
or her to be of sound mind. I did not sign the declarant's
signature above for or at the declaration of the declarant. I 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 or under any will of declarant or codicil
thereto, or directly financially responsible for declarant's
medical care.
Witness ______________________________________________
Witness ______________________________________________
Date: ___________________________________________