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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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DECLARATION PROVIDED BY COLORADO MEDICAL TREATMENT DECISION ACT,
COLORADO STATUTES 15-18-104
DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT
I _____________, being of sound mind and at least eighteen years
of age, direct that my life shall not be artificially prolonged
under the circumstances set forth below and hereby declare that:
1. If at any time my attending physician and one other physician
certify in writing that:
a. I have an injury, disease, or illness which is not curable
or reversible and which, in their judgment, is a terminal
condition; and
b. For a period of forty-eight consecutive hours or more, I
have been unconscious, comatose, or otherwise incompetent so as to
be unable to make or communicate responsive decisions concerning
my person; then,
I direct that life-sustaining procedures shall be withdrawn
and withheld, it being understood that life-sustaining procedures
shall not include any medical procedure or intervention for
nourishment or considered necessary by the attending physician to
provide comfort or alleviate pain.
2. I execute this declaration, as my free and voluntary act,
this ___________________ day of _____________________, 19______.
By ___________________________________
___________________________, Declarant
The foregoing instrument was signed and declared by ________
_______ to be his declaration, in the presence of us, who, in his
presence, in the presence of each other, and at his request have
signed our names below as witnesses, and we declare that, at the
time of the execution of this instrument, the declarant,
according to our best knowledge and belief, was of sound mind and
under no constraint or undue influence.
Dated at _______, _______, this ___________
day of _____________________________________, 19________.
________________________________________________________
Name and address
________________________________________________________
Name and address
STATE OF COLORADO
COUNTY OF ______________
Subscribed and sworn to before me by _________________,
the declarant, and __________________________________, and
____________________________________, witnesses, as the voluntary
act and deed of the declarant, this ________________ day of
____________________ 19________.
________________________________________
Notary Public