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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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1993-08-01
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110 lines
UNIFORM LIVING WILL
OF Irving Titlebaum
To my family, my physician, my lawyer, my clergyman. To any
medical facility in whose care I happen to be. To any individual
who may become responsible for my health, welfare or affairs.
Death is as much a reality as birth, growth, maturity and old age
-- it is the one certainty of life. If the time comes when I,
Irving Titlebaum, can no longer take part in decisions of my own
future, let this statement stand as an expression of my wishes
while I am still of sound mind.
If the situation should arise in which I am in terminal state and
there is no reasonable expectation of my recovery, I direct that I
be allowed to die a natural death and that my life not be
prolonged by extraordinary measures. I do, however, ask that
medication be mercifully administered to me to alleviate suffering
even though this may shorten my remaining life.
This statement is made after careful consideration and is in
accordance with my strong convictions and beliefs. I want the
wishes and directions here expressed carried out to the extent
permitted by law. Insofar as they are not legally enforceable, I
hope that those to whom this will is addressed will regard
themselves as morally bound by these provisions.
If it is permissible under the laws of the jurisdiction in which I
may be hospitalized I direct that the physicians supervising my
care upon a terminal diagnosis to discontinue hydration (water)
should the continuation of hydration be judged to result in unduly
prolonging a natural death.
If it is permissible under the laws of the jurisdiction in which I
may be hospitalized I direct that the physicians supervising my
care upon a terminal diagnosis to discontinue feeding should the
continuation of hydration be judged to result in unduly
prolonging a natural death.
I herewith release any and all hospitals, physicians, and others
both for myself and for my estate from any and all liability for
complying with this declaration, to the fullest extent provided by
law.
I herewith authorize my spouse, if any, or any relative who is
related to me within the third degree to effectuate my transfer
from any hospital or other health care facility in which I may be
receiving care should that facility decline or refuse to
effectuate the instructions given herein.
Signed:
_______________________________________________________________
Irving Titlebaum
City of residence: Buffalo
County of residence: Clark
State of residence: New York
Social Security Number: 123-45-0987
Date: _________________
________________________________________________________________
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 Irving Titlebaum, 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 Irving Titlebaum, declarant, and in his presence, and that
Irving Titlebaum 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