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A declaration may, but need not be, in the following form:
STATE OF RHODE ISLAND
RIGHTS OF THE TERMINALLY ILL ACT
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.
includes [ ]
|does not include [ ]|
the withholding or withdrawal of artificial feeding. (check only one box above)
Signed this ________________ day of ________________, _______.
Signature of Declarant
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.