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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 OF INTENTION PROVIDED BY MISSISSIPPI WITHDRAWAL OF LIFE
SAVING MECHANISMS ACT, MISSISSIPPI CODE 41-41-107
DECLARATION made on ___________ by ___________________
of ____________, _______________,
I, ________________, being of sound mind, declare that if
at any time I should suffer a terminal physical condition which
causes me severe distress or unconsciousness, and my physician,
with the concurrence of two (2) other physicians, believes that
there is no expectation of my regaining consciousness or a state
of health that is meaningful to me and but for the use of
life-sustaining mechanisms my death would be imminent, I desire
that the mechanisms be withdrawn so that I may die naturally.
However, 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 further declare that
this declaration shall be honored by my family and my physician
as the final expression of my desires concerning the manner in
which I die.
SIGNED:
________________________________________________________________
Social Security number: ___________
I hereby witness this declaration and attest that:
(1) I personally know the declarant and believe the
Declarant to be of sound mind.
(2) To the best of my knowledge, at the time of the
execution of this declaration, I:
(a) Am not related to the Declarant by blood or marriage,
(b) Do not have any claim on the estate of the Declarant,
(c) Am not entitled to any portion of the Declarant's
estate by any will or operation of law, and
(d) Am not a physician attending the declarant or a
person employed by a physician attending the declarant.
WITNESS:
________________________________________________________________
Address:
WITNESS:
________________________________________________________________
Address: