#5550
@001 Please state the name of the declarant:
@002 Please state the city where signed:
@003 Please state the parish where signed:
@004 Please state the state where signed: 
#end control section
#5550
/* Louisiana Living Will Form */


STATUTORY DECLARATION IN CONFORMANCE WITH LOUISIANA NATURAL DEATH
ACT, LOUISIANA R.S. 40:1299.58.3


             DECLARATION OF @001



	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, do hereby declare:

	If at any time I should have an incurable injury,

disease, or illness certified to be a terminal and irreversible

condition by two physicians who have personally examined me, 

one of whom shall be my attending physician, and the physicians 

have determined that my death will occur whether or not life-

sustaining procedures are utilized and where the application

of life-sustaining 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withheld or withdrawn, and that I be permitted to die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 administration of medication 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 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 from such refusal.

	I understand the full import of this declaration and

I am emotionally and mentally competent to make this 

declaration.


 
________________________________________
@001
 City of residence: @002
 Parish 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: _________________________