Kansas Living Will Declaration FormKansas Living Will Declaration Form
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Declaration made this _____ day of __________________, 20___.
I, _________________________________, date of birth ________________, of ________________ (city),
________________ (county), and _______________________ (state), 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, subject
to later revocation, and do hereby declare:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal 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 procedures would only serve to prolong the dying process, I direct that such procedures be withheld or
withdrawn and that I be permitted to die naturally with only the