#5530
@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
#5530
/* Indiana living will form*/
STATUTORY DECLARATION IN CONFORMANCE WITH INDIANA LIVING
WILL AND LIFE-PROLONGING PROCEDURES ACT, INDIANA CODE
16-8-11-12

             LIVING WILL DECLARATION OF @001


    Declaration made this __________ day of


_________________ 19________. I ,@001, being at least
eighteen (18) years old and of sound mind, willfully and
voluntarily make known my desires that my dying shall not be
artificially prolonged under the circumstances set forth below,
and I declare:


	If at any time I should have an incurable and
irreversible injury, disease, or illness certified in writing
to be a terminal condition by my attending physician, and my
attending physician has determined that my death will occur in a
short period of time, and the use of life-prolonging procedures
would serve only to artificially prolong the dying process, I
direct that such procedures be withheld or withdrawn, and that I
be permitted to die naturally with only the provision of
appropriate nutrition and hydration and the administration of
medication and 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 prolonging 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 of the refusal.


	I understand the full import of 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. I did not sign the
declarant's signature above for or at the direction of the
declarant. I am not a parent, spouse, or child of the declarant.
I am not entitled to any part of the declarant's estate or
directly financially responsible for declarant's medical care.
I am competent and at least eighteen (18) years old.




Witness         _________________________________________________





Witness         _________________________________________________




Date:   _______________________