Free living will template 29
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Name_ ___________________________________________________________
Medical record #__________________________________________________

HEALTH CARE DIRECTIVE (LIVING WILL)
Directive made this_____ day of____________________________________, (Year) .
I, ____________________________________________________________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 that:
(A) If at any time I should have an incurable and irreversible condition certified to be a terminal condition by my
attending physician, and where the application of life-sustaining treatment would serve only to artificially
prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be
permitted to die naturally. I understand “terminal condition” means an incurable and irreversible condition
caused by injury, disease, or illness that would, within reasonabl