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5520.ARM
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/* Illinois living will form*/
STATUTORY DECLARATION IN CONFORMANCE WITH ILLINOIS NATURAL DEATH
ACT, IL. STAT. 110 1/2 PARAGRAPH 703
DECLARATION OF @001
This declaration is made this __________ day of
____________________ 19________. I @001, being
of sound mind, willfully and voluntarily make known my desires
that my moment of death shall not be artificially postponed.
If at any time I should have an incurable and
irreversible injury, disease, or illness judged to be a terminal
condition by my attending physicians who has personally examined
me, and has determined that my death is imminent except for death
delaying procedures, I direct that such procedures which would
serve only to prolong the dying process be withheld or withdrawn,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 death 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 from such refusal.
________________________________________
@001
City of Residence: @002
County of Residence: @003
State of Residence: @004
Date: __________________________________
Witness _________________________________________________
Witness _________________________________________________
Date: ___________________________________