#5510
@001 Please state the name of the declarant:
@002 Please state the name of terminal condition:
@003 Please state the doctor's name:
@004 Please state the doctor's address (City, State):
@005 Please state the doctor's telephone number:
@006 Please state the county where signed: 
#end control section
#5510
/* Idaho living will law*/


DIRECTIVE TO PHYSICIANS AS PROVIDED BY IDAHO
NATURAL DEATH ACT, IDAHO CODE SECTION 39-4504

                     DIRECTIVE TO PHYSICIANS


Directive made this _________________ day of ___________. I
@001, being of sound mind, willfully and
voluntarily make known my desire that my life shall not be
artificially prolonged under the circumstances below:


1. In the absence of my ability to give directions regarding
the use of artificial life-sustaining procedures as result of
the disease process of my terminal condition, it is my
intention that such artificial life-sustaining procedures
should not be used when they would serve only to artificially
prolong the moment of my death and where my physician determines
that my death is imminent whether or not life-sustaining
procedures are utilized.


2. I have been diagnosed and notified that I have a
terminal condition known as @002 by @003 M.D. whose address is
@004, and whose telephone number is @005.


3. This directive shall have no force and effect five years
from the date filled in above.


4. I understand the full import of this directive and I am
emotionally and mentally competent to make this directive.




	Signed _________________________________________________


 STATE OF IDAHO


 COUNTY OF @006



	We, _________________________, _______________________ ,


and _____________________________, the qualified patient and
the witnesses respectively, who names are signed to the attached
and foregoing instrument, being first duly sworn, do hereby
declare to the undersigned authority that the qualified patient
signed and executed the directive and the he signed willingly
and he executed it as his free and voluntary act for the
purposes therein expressed; and that each of the witnesses,
in the presence and hearing of the qualified patient signed
the directive as witness and that to the best of his knowledge
the qualified patient was at the time 18 or more years of age,
of sound mind and under no constraint or undue influence. We the
undersigned witnesses further declare that we are not related
to the qualified patient by blood or marriage; that we are not
entitled to any portion of the estate of the qualified patient
upon his decease under any will or codicil thereto presently
existing or by operation of law then existing; that we are not
the attending physician, an employee of the attending physician
or a health facility in which the qualified patient is a patient,
and that we are not a person who has a claim against any portion
of the estate of the qualified patient upon his decease at the
present time.





                ________________________________________________
                Qualified Patient


	Subscribed, sworn to and acknowledged before me by


_______________________, the qualified patient, and subscribed


and sworn to before me by ______________________________________


and _____________________, witnesses, this ______________ day of


______________________, 19_______.





                ________________________________________________
                Notary Public for the State of Idaho


                Residing at __________________________, Idaho