X-Message-Number: 25915
From: "James Clement" <>
Subject: Living Sample - modify to suit your own beliefs & desires
Date: Tue, 29 Mar 2005 07:23:39 -0500
Living Will
Declaration that my existence be prolonged by extraordinary means, including
artificial nutrition or hydration, even if my condition is determined to be
terminal and incurable or if I am diagnosed as being in a persistent vegetative
state. I am aware and understand that this writing authorizes a physician NOT to
withhold or discontinue extraordinary means or artificial nutrition or
hydration in accordance with my specifications set forth below:
I, ________________________________________________________, being of sound
mind, declare my position regarding the prolongation of life as follows:
That I believe that "I" exist to the extent that I have DNA which is capable of
being stored for the purpose of, or immediately utilized via, somatic cell
nuclear transfer to create a genetically similar or identical being or any
sentient part thereof.
That I believe that my most important attribute consists of my memories, and
that the preservation of my neurophysiological essence is of utmost importance.
That I believe that it is within Man's ability to understand anything in Nature,
and that Man's knowledge of medicine has witnessed an astonishing growth in the
past several centuries, and that any physical condition from which I may
suffer, will at sometime in the future be curable and/or repairable.
That, whether Culture evolves at the same rate as Technology, I believe that I
have the personal temperament and desire to survive in any future society or
culture.
Therefore, I desire that my existence be prolonged by extraordinary means,
including artificial nutrition or hydration, even if my condition is determined
to be terminal and incurable or if I am diagnosed as being in a persistent
vegetative state. I am aware and understand that this writing authorizes a
physician NOT to withhold or discontinue extraordinary means or artificial
nutrition or hydration in accordance with my specifications set forth below.
Initial any of the following as desired:
If my condition is determined to be terminal and incurable or if I should lapse
into a persistent vegetative state, I authorize the following:
______For as long as there is any hope that my condition may change for the
better, regardless of the time factor or technological obstacles, I wish that
any and all extraordinary means be used to keep my body, and most importantly,
my brain cells alive.
If with regard to any of the conditions set forth above it is determined that I
am undergoing an irreversible neurophysiological breakdown (including but not
limited to senile dementia), I authorize the following:
______For medical personnel to immediately notify the Alcor Medical Director at
1-800-367-2228 or 1-480-922-9013 regarding my condition. I have previously
agreed to a whole-body anatomical donation for cryonics research to the Alcor
Life Extension Foundation, Inc. and have authorized them to take possession of
the donation under the Uniform Anatomical Gift Act. It is imperative for
medical research that they be contacted and their instructions followed
immediately. In the event of my death, and in furtherance of my anatomical
donation, it is imperative that I not be embalmed or autopsied.
This the ______day of ____________________, year_______________
Signature ___________________________________________________
STATEMENT
I hereby state that the Declarant, ____________________________________________
, being of sound mind, signed the attached declaration in my presence; and that
I am not related to the Declarant by blood or marriage; and that I do not know
or have a reasonable expectation that I would be entitled to any portion of the
estate of the Declarant under any existing will or codicil of the Declarant or
as an heir under the Intestate Succession Act if the Declarant died on this date
without a will. I also state that I am not the Declarant's attending physician
or an employee of the Declarant's attending physician or an employee of a health
facility in which the Declarant is a patient or an employee of a nursing home
or any group-care home where the Declarant resides. I further state that I do
not now have any claim against the Declarant.
Witness:__________________________________________________
Witness:__________________________________________________
COUNTY OF }
} S.S.
STATE OF }
I hereby certify that __________________________________the Declarant, appeared
before me and swore to me and to the witnesses in my presence that this
instrument is his/her Declaration of a Desire For a Natural Death, and that
he/she had willingly and voluntarily made and executed it as his/her free act
and deed for the purposes expressed in it.
I further certify that:
___________________________ and
___________________________,
witnesses, appeared before me and swore that they witnessed
______________________, Declarant, sign the attached Declaration, believing
him/her to be sound of mind; and also swore that at the time they witnessed the
Declaration (i) they were not related within the third degree to the Declarant
or to the Declarant's spouse, and (ii) they did not know or have a reasonable
expectation that they would be entitled to any portion of the estate of the
Declarant upon the Declarant's death under any will of the Declarant or codicil
thereto then existing or under the Intestate Succession Act as it provides at
that time, and (iii) they were not a physician attending the Declarant or an
employee of an attending physician or an employee of a health facility in which
the Declarant was a patient or an employee of a nursing home or any group-care
home in which the Declarant resided, and (iv) they did not have a claim against
the Declarant. I further certify that I am satisfied as to the genuineness and
due execution of the Declaration.
This the ____________ day of __________________ , year ___________________
________________________________________
Notary
My commission expires:____________________________________
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