Example of a Living Will

 

“Living Will”

(Declaration)

 

Pursuant to AS 18.12.010, I           Jane Marie Doe                         ,

 

of       211 Alaska Way, Cicely, Alaska  99999                                 ,

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.

 

I you desire to include the following options please initial the blank opposite the category:

 

                        do desire that nutrition or hydration (food & water) be provided by gastric tube or intravenously if necessary.

 

       JMD           I do not desire that nutrition or hydration (food & water) be provided by gastric tube or intravenously if necessary.

 

       JMD           Other directives are as follows:

 

                        No cardio pulmonary resuscitation nor respirators, please medicate for pain control.  Do no transport me from village. 

 

Signed this        22     day of                           November , 2000

 

                                                                 Jane Marie Doe               

                                                   Signature of Declarant

 

                                                               Fairbanks, Alaska             

                                                   Place of Signing

 

The declarant is known to me and voluntarily signed or voluntarily directed another to sign this document in my presence.

 

                                                                 Terry L. Braun               

                                                   Signature of Witness

 

                                                   2206 NE Broadway, N.Y.  10031 

 

 

                                                                    Susie Dawe                 

                                                   Signature of Second Witness

 

                                                   1920 Smith Drive, Fairbanks, AK 99709

                                                   Complete Address of Second Witness

}  ss.

        State of Alaska

        ___4th_______ Judicial District

 

The foregoing instrument was acknowledged before me by

 

__________Mary May______________________ this __22nd_____ day of

 

__November______, 2000___, at _Cicely________, 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.s