Free living will template 22
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STATE OF LOUISIANA
DECLARATION
Declaration made this
I,

day of

,

(month, year).
, being of sound

mind, willfully and voluntarily make known my desire that my dying shall not be artificially
prolonged under the circumstances set forth below and do hereby declare:
If at any time I should have an incurable injury, disease or illness, or be in a continual
profound comatose state with no reasonable chance of recovery, certified to be a terminal and
irreversible condition by two physicians who have personally examined me, one of whom shall
be my attending physician, and the physicians have determined that my death will occur whether
or not life-sustaining procedures are utilized and where the application of life-sustaining
procedure would serve only to prolong artificially the dying process, I direct (initial one only):
That all life-sustaining procedures, including nutrition and hydration,
be withheld or withdrawn so that food and water will not be administered invasively.
That life-sus