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1993-08-01
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STATUTORY DECLARATION IN CONFORMANCE WITH NEW HAMPHSIRE TERMINAL
CARE DOCUMENT LAW, N.H. R.S. 137-H: 3
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procedures be withheld or withdrawn, and that I be permitted to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,
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 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.
_______________________________________
Signature- _____________
State of _______________
_________ County
We, the declarant and the witnesses, being duly sworn each
declare to the notary public or justice of the peace or other
official signing below as follows:
1. The declarant signed the instrument as a free and voluntary act
for the purposes expressed, or expressly directed another to sign
for him.
2. Each witness signed at the request of the declarant, in his
presence, and in the presence of the other witness.
3. To the best of my knowledge at the time of the signing the
declarant was at least 18 years of age, and was of sane mind and
under no constraint or undue influence.
______________________________________________
Declarant
________________________________________________
Witness
________________________________________________
Witness
Sworn to and signed before me by ____________ declarant, and
___________________________ witnesses on _____________________,
199____.
___________________________________________________ Signature
Official Capacity: _____________________