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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 WEST VIRGINIA NATURAL
DEATH ACT, 16-30-3
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 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 is 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procedures be withheld or withdrawn, and that I be permitted to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 nutrition,
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 from such refusal.
I understand the full import of this declaration and I am
emotionally and mentally competent to make this declaration.
________________________________________
Signature- _____________________
Address: _______________________
_______________________
I did not sign the declarant's signature above for or at the
direction of the declarant. I am at least eighteen years of age
and am not related to the declarant by blood or marriage,
entitled to any portion of the estate of the declarant according
to the laws of intestate succession of the State of West
Virginia, or to the best of my knowledge under any will of
declarant or codicil thereto, or directly financially responsible
for declarant's medical care. I am not the declarant's attending
physician, an employee of the attending physician, nor an
employee of the health facility in which the declarant is a
patient.
________________________________________________
Witness
________________________________________________
Witness
STATE OF ________________________
COUNTY OF _______________________
This day personally appeared before me, the undersigned
authority, a Notary Public in and for ______________ County,
___________________________State, ______________________________
_______________________________(Witnesses) who, being first being
duly sworn, say that they are the subscribing witnesses to the
declaration of ________________, the declarant, signed, sealed
and published and declared the same as and for his declaration,
in the presence of both these affiants; and that these affiants,
at the request of said declarant, in the presence of each other,
and in the presence of said declarant, all present at the same
time, signed their names as attesting witnesses to said
declaration.
Affiants further say that this affidavit is made at the request
of _________________, declarant, and in his presence, and that
________________ at the time the declaration was executed, in the
opinion of the affiants, of sound mind and memory, and over the
age of eighteen years.
Taken, subscribed and sworn to before me by ____________
___________ (witness) and ____________________________ (witness)
this _______ day of __________________________________, 19_____.
My commission expires: __________________
___________________________________
Notary Public