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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 INDIANA LIVING WILL AND
LIFE-PROLONGING PROCEDURES ACT, INDIANA CODE 16-8-11-12
LIVING WILL DECLARATION OF Daniel Qualle
Declaration made this __________ day of
_________________ 19________. I ,Daniel Qualle, being at least
eighteen (18) years old and of sound mind, willfully and
voluntarily make known my desires that my dying shall not be
artificially prolonged under the circumstances set forth below,
and I declare:
If at any time I should have an incurable and irreversible
injury, disease, or illness certified in writing to be a terminal
condition by my attending physician, and my attending physician
has determined that my death will occur in a short period of time,
and the use of life-prolonging 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procedures be withheld or withdrawn, and that I be permitted to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 provision of appropriate nutrition and
hydration and the administration of medication and 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 prolonging 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 of the refusal.
I understand the full import of this declaration.
________________________________________ Daniel Qualle
City of Residence: Indianapolis
County of Residence: Franklin
State of Residence: Indiana
Date:
The declarant has been personally known to me and I believe him
or her to be of sound mind. I did not sign the declarant's
signature above for or at the direction of the declarant. I am not
a parent, spouse, or child of the declarant. I am not entitled to
any part of the declarant's estate or directly financially
responsible for declarant's medical care. I am competent and at
least eighteen (18) years old.
Witness _________________________________________________
Witness _________________________________________________
Date: _______________________