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Fill and Sign the Rhode Island Will Formslast Will and Testamentliving Will

Fill and Sign the Rhode Island Will Formslast Will and Testamentliving Will

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DECLARATION (Rhode Island General Laws § 23-4.11-3) I, _____________________________________________________ being of sound mind willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare: If I should have an incurable or irreversible condition that will cause my death within a relatively short time, and if I am unable to make 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. This authorization includes ( ) does not include ( ) the withholding or withdrawal of artificial feeding (check only one box above). Signed this day of _________________________, 20 . Date: ________________________________ City: _____________________________________________________ State: _____________________________________________________ Signature: The declarant is personally known to me and voluntarily signed this document in my presence. Witness Signature: Residence Address: Print Name: Date: Witness Signature: Residence Address: Print Name: Date:

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