Living Will

Declaration Of A Desire For A Natural Death As Set Forth In The Right To A Natural Death Act

I, ________________________________________________________, being of sound mind, desire that, as specified below, my life not be prolonged by extraordinary means or by artificial nutrition or hydration if my condition is determined to be terminal and incurable or if I am diagnosed as being in a persistent vegetative state. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration in accordance with my specifications set forth below.

Initial any of the following as desired:

If my condition is determined to be terminal and incurable or if I should lapse into a persistent vegetative state, I authorize the following:

______My physician may withhold or discontinue extraordinary means only.

______ In addition to withholding or discontinuing extraordinary means, if such are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.

If my physician determines that I am in a persistent vegetative state, I authorize the following:

______My physician may withhold or discontinue extraordinary means only.

______In addition to withholding or discontinuing extraordinary means, if such are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.

This the ______day of ____________________, year_______________

Signature ___________________________________________________ I hereby state that the

Declarant,___________________________________________________ , being of sound mind, signed the attached declaration in my presence; and that I am not related to the Declarant by blood or marriage; and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the Declarant under any existing will or codicil of the Declarant or as an heir under the Intestate Succession Act if the Declarant died on this date without a will. I also state that I am not the DeclarantÂ’s attending physician or an employee of the DeclarantÂ’s attending physician or an employee of a health facility in which the Declarant is a patient or an employee of a nursing home or any group-care home where the Declarant resides. I further state that I do not now have any claim against the Declarant.

Witness:__________________________________________________

Witness:__________________________________________________

Certificate

I,______________________________________________________________ Clerk (Assistant Clerk) of

Superior Court or Notary Public (circle one as appropriate) for___________________________________

County, North Carolina, hereby certify that __________________________________the Declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his/her Declaration of a Desire For a Natural Death, and that he/she had willingly and voluntarily made and executed it as his/her free act and deed for the purposes expressed in it.

I further certify that ___________________________ and ___________________________,

witnesses, appeared before me and swore that they witnessed _____________________________, Declarant, sign the attached Declaration, believing him/her to be sound of mind; and also swore that at the time they witnessed the Declaration (i) they were not related within the third degree to the Declarant or to the DeclarantÂ’s spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the Declarant upon the DeclarantÂ’s death under any will of the Declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the Declarant or an employee of an attending physician or an employee of a health facility in which the Declarant was a patient or an employee of a nursing home or any group-care home in which the Declarant resided, and (iv) they did not have a claim against the Declarant. I further certify that I am satisfied as to the genuineness and due execution of the Declaration.

This the ____________ day of __________________ , year ___________________

________________________________________ Clerk (Assistant Clerk) of Superior Court or

Notary Public for the County of _______________________________, State of North Carolina.

My commission expires:____________________________________

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