#5590
@001 Please state the name of the declarant:
@002 Please state the declarant's city of residence:
@003 Please state the declarant's state of residence:
@004 Please enter the declarant's social security number: 
#end control section
#5590
/* Mississippi Living Will */
DECLARATION OF INTENTION PROVIDED BY MISSISSIPPI
WITHDRAWAL OF LIFE SAVING MECHANISMS ACT, MISSISSIPPI
CODE 41-41-107


	DECLARATION made on ___________ by @001 

of @002, @003,


	I, @001, being of sound mind, declare that if at any

time I should suffer a terminal physical condition which causes

me severe distress or unconsciousness, and my physician, with the

concurrence of two (2) other physicians, believes that there is

no expectation of my regaining consciousness or a state of health

that is meaningful to me and but for the use of life-sustaining

mechanisms my death would be imminent, I desire that the mechan-

isms be withdrawn so that I may die naturally. However, if I have

been diagnosed as pregnant and that diagnosis is known to my

physician, this declaration shall have no force or effect during

the course of my pregnancy. I further declare that this declar-

ation shall be honored by my family and my physician as the final

expression of my desires concerning the manner in which I die.


SIGNED:





________________________________________________________________
@001

 Social Security number: @004


	I hereby witness this declaration and attest that:


	(1) I personally know the declarant and believe the

Declarant to be of sound mind.


	(2) To the best of my knowledge, at the time of the

execution of this declaration, I:


	(a) Am not related to the Declarant by blood or marriage,


	(b) Do not have any claim on the estate of the Declarant,


	(c) Am not entitled to any portion of the Declarant's


	estate by any will or operation of law, and


	(d) Am not a physician attending the declarant or a 

person employed by a physician attending the declarant.



WITNESS:




________________________________________________________________


Address:






WITNESS:




________________________________________________________________


Address: