                              A LIVING WILL 
 
                  A directive to withhold treatment and for 
                  the administration of pain-killing drugs 
 
 
To my family, my relatives, my physicians, my employers, and all
others whom 
it may concern: 
 
I, (name), of (address), City of (city), County of (county), State
of 
(state), being of sound mind, willfully, and voluntarily make known
my desire 
that my life shall not be prolonged artificially under the
circumstances set 
forth below, do hereby declare: 
 
1. If, at any time, I should have an incurable injury, disease,
illness, or 
condition certified to be terminal by two medical doctors who have
examined 
me, and where the application of life-sustaining procedures of any
kind would 
serve only to prolong artificially the moment of my death, and
where a 
medical doctor determines that my death is imminent, whether or not
life- 
sustaining procedures are utilized, I direct that such procedures
be withheld 
or withdrawn and that I be permitted to die naturally, and that I
receive 
whatever quantity of whatever drugs may be required to keep me free
of pain 
or distress even if the moment of death is hastened. 
 
2. In the absence of my ability to give directions regarding the
use of life- 
sustaining procedures, I hereby appoint (name) of (address), City
of (city), 
County of (county), State of (state), as my attorney-in-fact/proxy
for the 
purpose of making decisions relating to my health care in my place;
and it 
is my intention that this appointment shall be honored by him/her,
by my 
family, relatives, friends, physicians, and lawyer as the final
expression 
of my legal right to refuse medical or surgical treatment; and I
willfully 
accept the consequences of such a decision.  I have duly executed
a Durable 
Power of Attorney for health care on this date. 
 
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Under California law, for such an appointment to be as fully
effective as 
the law will permit, it must be in the form included under the
title "DURABLE 
POWER OF ATTORNEY FOR HEALTH CARE CONDITIONS."  Persons living in
other 
states and executing this "Living Will" also might wish to execute
that same 
Durable Power of Attorney form, since it might be honored by the
courts of 
any particular state. 
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3. In the absence of my ability to give further directions
regarding my 
treatment, including life-sustaining procedures, it is my willful
intention 
that this directive shall be honored by my family and physicians
as the final 
expression of my legal right to refuse or accept medical or
surgical 
treatment, and I fully and willfully accept the consequences of
such refusal. 
 
4. If I have been diagnosed as pregnant and that diagnosis is known
to any 
interested person, this directive shall have no force during the
course of 
my pregnancy. 
 
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Males should strike out this paragraph entirely. 
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5. I have been diagnosed, and notified at least 14 days ago, as
being in a 
terminal condition by (physician's name), M.D., of (address), City
of (city), 
State of (state).  It is my intention that if I have not filled in
the 
physician's name and address, it shall be presumed that I did not
have a 
terminal condition when I completed this directive. 
 
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If you are not a resident of California, strike out this paragraph
entirely. 
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6.  I fully and completely understand the full importance of this
directive 
and am emotionally and mentally competent to make this directive. 
No 
participant in the making of this directive or on its being carried
into 
effect, whether it be a medical doctor, my spouse, a relative,
friend, or any 
other person shall be held responsible in any way, legally,
professionally 
or socially, for complying with my directions. 
 
In Witness Whereof, I have executed this directive on the date
entered below. 
 
 
_________________________ 
(Name)                         
 
 
_________________________     _________________________ 
Witness 1                     Witness 2 
 
 
Sworn to and subscribed before me this (day) day of (month),
19(year). 
 
 
My commission expires:          _________________________ 
                                Notary Public 
 
_________________________ 
Date 
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