#5520
@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
#5520
/* Illinois living will form*/


STATUTORY DECLARATION IN CONFORMANCE WITH ILLINOIS NATURAL DEATH
ACT, IL. STAT. 110 1/2 PARAGRAPH 703

                  DECLARATION OF @001


    This declaration is made this __________ day of
____________________ 19________. I @001, being
of sound mind, willfully and voluntarily make known my desires
that my moment of death shall not be artificially postponed.


	If at any time I should have an incurable and
irreversible injury, disease, or illness judged to be a terminal
condition by my attending physicians who has personally examined 
me, and has determined that my death is imminent except for death
delaying procedures, I direct that such  procedures which would
serve only to prolong the dying process be withheld or withdrawn,
and that I be permitted to die naturally with only the
administration of medication, sustenance, or the performance of
any medical procedure deemed necessary to provide me with comfort
care.


	In the absence of my ability to give directions
regarding the use of such death delaying procedures, it is
my intention that this declaration shall be honored by my
family and physician as the final expression of my legal right
to refuse medical or surgical treatment and accept the
consequences from such refusal.




________________________________________
 @001


 City of Residence: @002
 County of Residence: @003
 State of Residence: @004




			Date: __________________________________




 Witness        _________________________________________________





 Witness        _________________________________________________


                       Date: ___________________________________