I, _________________, declare that if I should lapse into a persistent vegetative state or have an incurable and irreversible condition that, without the administration of life&endash;sustaining treatment, will, in the opinion of my attending physician, cause my death within a reasonably short time and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Rights of the Terminally Ill Act, to withhold or withdraw life sustaining treatment that is not necessary for my comfort or to alleviate pain.

Date signed: ____________________.

__________________________________

The declarant voluntarily signed this writing in my presence.

 

Witness___________________________

Address___________________________

Witness___________________________

Address___________________________

-or-

The declarant voluntarily signed this writing in my presence.

 

__________________________________

Notary Public