Fill and Sign the Missouri Statutory Form

DECLARATION (Missouri Revised Statutes 459.010 to 459.055) I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical tre atment, I direct my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying. Signed this day of ____________________, 20 Signature ________ City, County and State of residence ____________________ The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence. Witness Address _______________________________________ Witness Address _______________________________________ REVOCATION PROVISION I hereby revoke the above declaration. Signed (Signature of Declarant) Date ____________________