Fillable Printable Living Will Declaration

Living Will Declaration

This declaration is made this __________ day of_______________________________________(month, year).

I, ___________________________________________________, 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 physician 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delaying procedures, I direct that such procedures which would only prolong the dying process be withheld or withdrawn,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 by my attending physician 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.

Signed ___________________________________________________________________________________________

City, County and State of Residence ___________________________________________________________________

The declarant is personally known to me and I believe him or her to be of sound mind. I saw the declarant sign the

declaration in my presence (or the declarant acknowledged in my presence that he or she had signed the declaration) and I

signed the declaration as a witness in the presence of the declarant. I did not sign the declarant’s signature above for or at

the direction of the declarant. At the date of this instrument, I am not entitled to any portion of the estate of the declarant

according to the laws of intestate succession or, to the best of my knowledge and belief, under any will of declarant or

other instrument taking effect at declarant’s death, or directly financially responsible for declarant’s medical care.

Witness __________________________________________________________________________________________

History

(Source: P.A. 85-1209.)

Annotations

Note. This section was Ill.Rev.Stat., Ch. 110 1/2, Para. 703.

DLiving Willd

DECLARATION