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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 FLORIDA LIFE PROLONGING
PROCEDURE ACT, F.S. 765.05
DECLARATION OF ________________________
Declaration made this __________ day of _____________
19________. I ___________ willfully and voluntarily
make known my desire that my dying shall not be artificially
prolonged under the circumstances set forth below, do hereby
declare:
If at any time I should have a terminal condition,
and if my attending physician has determined that there can
be no recovery from such condition and my death is imminent,
I direct that such procedures be withheld or withdrawn, and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 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 for such refusal.
If I have been diagnosed as pregnant and that
diagnosis is known to my physician, this declaration shall have
no force or effect during the course of my pregnancy.
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.
___________________________________________
Witness:
___________________________________________
Witness:
Date: ___________________________