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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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1993-08-01
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109 lines
OKLAHOMA STATUTES TITLE 63 SECTION 3103
DIRECTIVE TO PHYSICIANS
Directive made this _________________ day of ___________.
I Leonard Shatner, being of sound mind and twenty-one years of
age or older, willfully and voluntarily make known my desire that
my life shall not be artificially prolonged under the
circumstances set forth below, and do hereby declare:
1. If at any time I should have an incurable irreversible
condition caused by injury, disease, or illness certified to be a
terminal condition by two physicians, I direct that life-
sustaining procedures be withheld or withdrawn and that I be
permitted to die naturally, if the application of life-sustaining
procedures would serve only to artificially prolong the moment of
my death and where my physician determines that my death is
imminent whether or not life-sustaining procedures are utilized;
2. In the absence of my ability to give directions regarding the
use of such life-sustaining procedures, it is my intention that
this directive shall be honored by my family and physician(s) as
the final expression of my legal right to refuse medical or
surgical treatment and accept the consequences of such refusal;
3. If I have been diagnosed as pregnant and that diagnosis is
known to my physician, this directive shall have no force or
effect during the course of my pregnancy;
4. I have been diagnosed and notified as having a terminal
condition by Kelly D. Forest, M.D., M.D. or D.O. whose address is
Burke, Oklahoma. I understand that if I have not filed in the
name and address of the physician, it shall be presumed that I
did not have a terminal condition when I made out this directive;
5. This directive shall be in effect until revoked;
6. I understand the full import of this directive and I am
emotionally and mentally competent to make this directive; and
7. I understand that I may revoke this directive at any time.
Signed _________________________________________________
Leonard Shatner
The declarant has been personally known to me and I believe him
or her to be of sound mind. I am twenty-one (21) years of age or
older, I am not related to the declarant by blood or marriage,
nor would I be entitled to any portion of the estate of the
declarant upon the death of the declarant, nor am I the attending
physician or directly financially responsible for declarant's
medical care, or any person who has a claim against any portion
of the estate of the declarant upon the death of the declarant.
________________________________________________________________
WITNESS
________________________________________________________________
WITNESS
State of Oklahoma)
County of _____________________)
Before me, the undersigned authority, on this day personally
appeared Leonard Shatner declarant, ____________________________
witness and ________________________________ witness whose names
are subscribed to the foregoing instrument in their respective
capacities, and, all of said persons being by me duly sworn, the
declarant declared to me and to the said witnesses in my presence
that said instrument is his or her "Directive to Physicians", and
that the declarant had willingly and voluntarily made and executed
it as the free act and deed of the declarant for the purposes
therein expressed.
The foregoing instrument was acknowledged before me this
___________________ day of ______________________, 19__________.
Signed:
__________________________________________________________
Notary Public in and for ____________ County, Oklahoma
My Commission Expires: