Fillable Printable Three-Page Living Will
Fillable Printable Three-Page Living Will
Three-Page Living Will
Living Will
To: My Family, my physician, my Lawyer, my Clergyman, any Medical Facility in whose care I
happen to be and any individual who may become responsible for my Health, Welfare or Affairs:
If the time comes when I can no longer take part in decisions concerning my life, I wish and
direct the following:
If a situation should arise in which there is no reasonable expectation for my recovery from
extreme physical or mental disability, I direct that I be allowed to die, and not be kept alive by
medications, artificial means, life support equipment or “heroic 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 convictions and
beliefs. I urge those concerned to take whatever action necessary, including legal action, to fulfill my
wishes and directions. To the extent that the provisions of this document are not legally enforceable, I
hope that those to whom it is addressed will regard themselves as morally bound by it.
Elective Provisions
Check the box and write initials next to each election you desire.
1. I wish to live out my last days at home rather then in a hospital if it does not jeopardize the
chance of my recovery to a meaningful and conscious life and does not impose an undue burden on my
family.
2. If any of my tissues or organs are sound and would be of value as transplants to other
people, I freely give my permission for such donations.
In Witness Whereof, I state that I have read this, my living will, know and understand its contents
and sign my name below.
Dated , 20
Witness
Witness
________________________________________
Print or type full name, address & tel. no. of person signing
Name
Address
Telephone
Name
Address
Telephone
Your state may have specific rules regarding this living will such as how long it will
be effective, requirements for witnesses, etc. Consult your attorney before signing.
Optional Acknowledgement
STATE OF
COUNTY OF ss.:
On , 20 before me personally came to me known, and known to me to be the
individual described in, and who executed the foregoing instrument, and he acknowledged to me that he
executed the same.
______________________________
