“Living Will”
(Declaration)
Pursuant to AS 18.12.010, I , Date of Birth ,
of ,
Complete address of declarant
declare that if I should have an incurable or
irreversible condition that will cause my death within a relatively short
time, it is my desire that my life not be prolonged by administration of
life-sustaining procedures. If my
condition is terminal and I am unable to participate in 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.
If you desire to
include the following options please initial the blank opposite the category:
I do desire that nutrition or hydration (food & water) be provided by
gastric tube or intravenously if necessary.
I do not desire that nutrition or hydration (food & water) be provided by gastric tube or intravenously if necessary.
Other directives are as follows:
Signed this day of , 20
Signature of Declarant
Place of Signing
The declarant is known to me and voluntarily
signed or voluntarily directed another to sign this document in my presence.
Signature of Witness
Signature of Second Witness
Complete Address of Second Witness
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State of Alaska
__________ Judicial District
The foregoing instrument was acknowledged
before me by _________________________
_____________________ this ________ day of
_______________, 20 ____, at
, Alaska.
Signature of Person Taking Acknowledgment
Notary Public for
My Commission Expires:
_______________________________
This Declaration
must either be witnessed by two persons at least eighteen (18) years of age
and not related to the declarant by blood or marriage, or acknowledged by a
person qualified to take acknowledgments under 09.63.010.