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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 ILLINOIS NATURAL DEATH
ACT, IL. STAT. 110 1/2 PARAGRAPH 703
DECLARATION OF ______________________
This declaration is made this __________ day of __________
19___________. I _____________________________, being of sound
mind, willfully and voluntarily make known my desires that my
moment of death shall not be artificially postponed.
If at any time I should have an incurable and irreversible
injury, disease, or illness judged to be a terminal condition by
my attending physicians who has personally examined me, and has
determined that my death is imminent except for death delaying
procedures, I direct that such procedures which would serve only
to prolong the dying process be withheld or withdrawn, and that I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 death delaying procedures, it is my intention that this
declaration shall be honored by my family and physician as the
final expression of my legal right to refuse medical or surgical
treatment and accept the consequences from such refusal.
________________________________________
City of Residence: ________________
County of Residence: ______________
State of Residence: _______________
Date: __________________________________
Witness _________________________________________________
Witness _________________________________________________
Date: ___________________________________