Fill and Sign the I Being of Sound Mind Willfully and Voluntarily Make This Form

DECLARATION (K.S.A. 65-28,103) Declaration made this _____ day of ___________________ (month, year). I, _____________________________________ being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged unde r the circumstances set forth below, do hereby declare: If at any time I should have an incurable injury, disease, or illness c ertified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death wi ll occur whether or not life-sustaining procedures are utilized and where the application of life -sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to prov ide me with comfort care. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my f amily and physician(s) as the final expression of my legal right to refuse medic al or surgical treatment and accept the consequences from such refusal. I understand the full import of this declaration and I am emotionally and m entally competent to make this declaration. Signed: _______________________________________________________________________ City, County and State of Residence: ____________________________________________________________________ The declarant has been personally known to me and I believe the declarant to be of sound mind. I did not sign the declarant's signature above for or at the direction of t he declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of decl arant or codicil thereto, or directly financially responsible for declarant's medical care. Witness _______________________________________________________________________ Witness _______________________________________________________________________ (OR) STATE OF _____________________________________ COUNTY OF _____________________________________ Th is instrument was acknowledged before me on _____________________________________ (date) by _________________________________________________________ (name of person). ____________________________________________________ (Signature of notary public) (Seal, if any) My appointment expires: _______________________________