Fill and Sign the Alaska Procedures 497293776 Form

DECLARATION RELATING TO USE OF LIFE - SUSTAINING PROCEDURES DECLARATION 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 ( ) do ( ) do not desire that nutrition or hydration (food and water) be provided by gastric tube or intravenously if necessary. Notwithstanding the other provisions of this declaration, if I have donated an organ under this declaration or by another method, and if I am in a hospital when a do not resuscitate order is to be implemented for me, I do not want the do not resuscitate order to take effect until the donated organ can be evaluated to determine if the organ is suitable for donation. OPTIONAL: In the event of my death, I donate the following part(s) of my body for the purposes identified in AS 13.52.207 : Tissue: __________________ Eyes: __________________ Bone and connective tissue: __________________ Skin: __________________ Heart: __________________ Other: __________________ Limitations: __________________ Organ: __________________ Heart: __________________ Kidney(s): __________________ Liver: __________________ Lung(s): __________________ Pancreas: __________________________________________________________ Other: __________________ Signed this _____ day of __________________ , 20 _____ . Signature____________________________ Place __________________ I swear under penalty of perjury under AS 11.56.200 that the principal is personally known to me, that the principal signed or acknowledged this durable power of attorney for health care in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, and that I am not (1) a health care provider employed at the health care institution or health care facility where the principal is receiving health care; (2) an employee of the health care provider providing health care to the principal; (3) an employee of the health care institution or health care facility where the principal is receiving health care; (4) the person appointed as agent by this document; (5) related to the principal by blood, marriage, or adoption; or (6) entitled to a portion of the principal's estate upon the principal's death under a will or codicil. __________________ (date) ______________________________________________________ (signature of witness) ________________________ (printed name of witness) ________________________ (address) (city) (state) (zip code) __________________ (date) ______________________________________________________ (signature of witness) ________________________ (printed name of witness) ________________________ (address) (city) (state) (zip code) State of ______________________ Judicial District ________________ ACKNOWLEDGMENT FORM The foregoing instrument was acknowledged before me this _______________________ (date) by ____________________________________ (name of person who acknowledged). _____________________________________ Signature of Person Taking Acknowledgment ____________________________________ Title or Rank ____________________________________ Serial Number, if any. AK-02005