#5300
@001 State the name of the declarant:
@002 Enter the state where executed:
@003 Enter the county where executed:
#end control section
#5300
/* HAWAII Living Will Form*/
DECLARATION  AS PROVIDED BY HAWAII REVISED STATUTES CHAPTER  327D
SECTION 4 

                           DECLARATION

A. Statement of Declarant

              Declaration  made  this __________________  day  of


_____________, 19_______. I, @001 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, and do hereby declare: 


              If at any time I should have an incurable or

irreversible condition certified to be terminal by two physicians

who have personally examined me, one of whom shall be my

attending physician, and the physicians have determined that I am

unable to make decisions concerning my medical treatment, and

that without administration of life-sustaining treatment my death

will occur in a relatively short time, and where the application

of life-sustaining procedures would serve only to prolong

artificially 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withheld or withdrawn, and that I be permitted to die naturally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, nourishment, or

fluids or the performance of any medical procedure deemed

necessary to provide me with comfort or to alleviate pain.


              I understand the full import of this declaration

and I am emotionally and mentally competent to make this

declaration.




Signed:




________________________________________________________________


@001


STATE OF @002


COUNTY OF @003



B. Statement of Witnesses


              I am at least 18 years of age and

-not related to the declarant by blood, marriage or adoption; and

-not the attending physician, an employee of the attending

physician, or an employee of the medical care facility in which

the declarant is a patient.


              The declarant is personally known to me and I

believe the declarant to be of sound mind. 


Witness:



_______________________________________________________________

Address:


Witness:



_______________________________________________________________

Address:



C) Notarization

              Subscribed, sworn to and acknowledged before me by

@001, the declarant, and subscribed and sworn to before me by


___________________ and ___________________, witnesses, this


______________ day of ________________________, 19_______.





                           _____________________________________


                           Official Capacity: _________________