Create Living Will
Declarant Information
Enter the declarant's personal details.
Live Preview
Living Will / Advance Directive
I, _______________, residing at _______________, _______________ , born on _______________, being of sound mind, willfully and voluntarily make this Living Will and Advance Directive. I direct that my wishes expressed herein be honored and carried out by my healthcare agent, family, physicians, and any other persons who may be responsible for my care. I understand that this document will have legal effect only when I am unable to communicate my own healthcare decisions.
Healthcare Agent
I hereby designate _______________, as my Healthcare Agent to make medical decisions on my behalf when I am unable to do so.
Address: _______________, _______________
Phone: _______________
Article I — Life-Sustaining Treatment
If I am in a terminal condition, persistent vegetative state, or irreversible coma, I direct my Healthcare Agent and attending physicians regarding life-sustaining treatment as follows:
_______________
Article II — Artificial Nutrition and Hydration
Regarding the provision of nutrition and hydration through artificial means (including but not limited to intravenous fluids, nasogastric tubes, or gastrostomy tubes), I direct as follows:
_______________
Article III — Pain Management
Regarding the management of pain and comfort care, I direct as follows:
_______________
Article IV — Organ Donation
Regarding the donation of my organs and tissues upon my death, I direct as follows:
_______________
Governing Law
This Living Will and Advance Directive shall be governed by and interpreted in accordance with the laws of the State of _______________.
IN WITNESS WHEREOF, I have signed this Living Will and Advance Directive on _______________.
Declarant Signature
Name: _______________
Date: _______________
Witness 1 Signature
Name: _______________
Address: _______________
Date: _______________
Witness 2 Signature
Name: _______________
Address: _______________
Date: _______________
Notary Acknowledgment
State of _______________
County of _______________
On this _______ day of _______________, 20____, before me, the undersigned notary public, personally appeared _______________, known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument, and acknowledged to me that they executed the same in their authorized capacity, and that by their signature on the instrument, the person, or the entity upon behalf of which the person acted, executed the instrument.
Notary Public Signature
My Commission Expires: _______________