Declaration made this the ______ day of ____________, 200__, I, _______________________, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

If at any time I should have a terminal condition and my attending and one (1) other physician in their discretion, have determined such condition is incurable and irreversible and will result in death within a relatively short time, and where the application of life-prolonging treatment would serve only to artificially prolong the dying process, I direct that such treatment by withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the
performance of any medical treatment deemed necessary to alleviate pain or for nutrition or hydration.

It is further my intent that any medical treatment for nutrition or hydration be administered for the single purpose of my quick recovery to a normal life. I do not desire that the said treatment for nutrition or hydration be administered to me for the single purpose of life prolonging. It is my desire that my attending and one (1) other physician in their discretion shall determine when the treatment for nutrition or hydration would serve only to artificially prolong the dying process. It is then my direction that such treatment for said nutrition or hydration to be withheld or withdrawn and that I be permitted to die naturally.

In absence of my ability to give directions regarding the use of such life-prolonging treatment, it is my intention that this declaration shall be honored by my attending physician and my family as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of such refusal.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

State Of Kentucky

County Of Magoffin

Before me, the undersigned authority, on this day personally appeared _________________________, Living Will Declarant, and _______________________ and _______________________ known to me to be witnesses whose names are each signed to the foregoing instrument , and all these persons being first duly sworn, __________________________, Living Will Declarant, declared to me and to the witnesses in my presence that the instrument is the Living Will Declaration of the declarant and that the declarant has willingly signed and that such declarant executed it as a free and voluntary act for the purposes therein expressed; and each of the witnesses stated to me, in the presence and hearing of the Living Will Declarant, that the declarant signed the declaration as witness and to the best of such witness's knowledge, the Living Will Declarant was eighteen (18) years of age or over, of sound mind and under no
constraint or undue influence.

State Of Kentucky

County Of Magoffin

Subscribed, sworn to and acknowledged before me by__________________, Living Will Declarant, and subscribed and sworn before me
by _________________________ and ___________________________ witnesses, on this the ______ day of ________________, 200______.

My Commission Expires:_______________

_______________________
Notary Public
Kentucky State At Large