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5500.BLD
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1993-01-06
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#5500
@001 Please state the name of the declarant:
@002 Please enter the state where executed:
@003 Please enter the county where executed:
#end control section
#5500
/* Iowa living will*/
DECLARATION AS PROVIDED BY IOWA CODE 144A.3
DECLARATION OF @001
If I should have an incurable or irreversible condition
that will cause my death within a relatively short time, it is
my desire that my life not be prolonged by administration of
life-sustaining procedures. If my condition is terminal and I
am unable to participate in decisions regarding my medical
treatment, I direct my attending physician to withhold or
withdraw procedures that merely prolong the dying process and
are not necessary to my comfort or freedom from pain.
Signed this _______________ day of _______________, 19_____
Signature:
________________________________________________________________
The declarant is known to me and voluntarily signed this
document in my presence.
Witness:
________________________________________________________________
Address:
Witness:
________________________________________________________________
Address: