#5007
@001 Please state the name of the declarant:
@002 Please state the city where signed:
@003 Please state the county where signed:
@004 Please state the state where signed: 
#end control section
#5007
/*Florida living will*/
STATUTORY DECLARATION IN CONFORMANCE WITH FLORIDA LIFE
PROLONGING PROCEDURE ACT, F.S. 765.05


             DECLARATION OF @001




	Declaration made this __________ day of _____________

19________.  I @001 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 at any time I should have a terminal condition,

and if my attending physician has determined that there can

be no recovery from such condition and my death is imminent,

I direct that such procedures be withheld or withdrawn, and 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 provide me with comfort care or 

to alleviate pain.


	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

family and physicians as the final expression of my legal right

to refuse medical or surgical treatment and accept the

consequences for such refusal.


	If I have been diagnosed as pregnant and that 

diagnosis is known to my physician, this declaration shall have 

no force or effect during the course of my pregnancy.  


	I understand the full import of this declaration and

I am emotionally and mentally competent to make this

declaration.




________________________________________

@001

City of residence: @002

County of residence: @003

State of residence: @004






			Date: ________________________


	The declarant has been personally known to me and

I believe him or her to be of sound mind.



                ___________________________________________
                Witness:




                ___________________________________________
                Witness:



Date: ___________________________