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  • Living Will Sample Form

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    A declaration may, but need not be, 
    in the following form:

    STATE OF RHODE ISLAND
    CHAPTER 23-4.11
    RIGHTS OF THE TERMINALLY ILL ACT

    DECLARATION

    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, so hereby declare:

    If I should have an incurable or irreversible condition that will cause my death within a relatively short time, and if I am unable to make decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort, or to alleviate pain.

     

    This authorization

    includes [ ]

     does not include [ ]

    the withholding or withdrawal of artificial feeding. (check only one box above)

     

    Signed this ________________ day of ________________, _______.

    ___________________________________
    Signature of Declarant

    ___________________________________
    Address

     

    The declarant is personally known to me and voluntarily signed this document in my presence.  I am not related to the declarant by blood or marriage.

    _______________________
    Witness

    __________________________ 
    Address

      
    _______________________
    Witness

    __________________________
    Address

     

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