Free living will template 05
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Instructions for using this document: This document has both a Living Will and Healthcare Power of Attorney.
Fill it out and sign it in front of two witnesses. If you want a Living Will and Healthcare Power of Attorney, you
will have to sign this document in two places.
BY: ________________________________________________________________________________
If I should have an incurable or irreversible condition that will cause my death within a relatively short time, and
I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant
to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act to withhold or withdraw treatment
that only prolongs the process of dying and is not necessary to my comfort or to alleviate pain.
The life-sustaining treatment that I want withheld or withdrawn, includes but is not limited to: (Check what you
want withheld or withdrawn.)

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