#5740
@001 State the name of the declarant:
@002 IF A TERMINAL DIAGNOSIS EXISTS State Dr.'s name:
@003 IF A TERMINAL DIAGNOSIS state city, state of Dr.:
@004 State the declarant's city of residence:
@005 State the declarant's county of residence:
@006 State the declarant's state of residence: 
#end control section
#5740
/* Texas Living Will--- Form */
DIRECTIVE TO PHYSICIANS AS PROVIDED BY TEXAS NATURAL
DEATH ACT SECTION 3


                     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 set forth below, and do hereby declare:


1. If at any time I should have an incurable condition
caused by injury, disease or illness certified to be a terminal
condition by two physicians, and where the application of life-
sustaining procedures would serve only to artificially prolong 
the moment of my death and where my attending physician
determines that my death is imminent whether or not
life-sustaining procedures are utilized, I direct that such
procedures be withheld or withdrawn, and that I be permitted to
die naturally.


2. In the absence of my ability to give directions regarding
the use of such life-sustaining procedures, it is my intention
that this directive shall be honored by my family and
physician(s) as the final expression of my legal right to refuse
medical or surgical treatment and accept the consequences from
such refusal.


3. If I have been diagnosed as pregnant and that diagnosis is
known to my physician, this directive shall have no force or
effect during the course of my pregnancy.


4. I have been diagnosed and notified at least 14 days ago as
having a terminal condition by @002, M.D., whose address is 
@003.


I understand that if I have not filed in the physician's name and
address, it shall be presumed that I did not have a terminal
condition when I made out this directive.


5. This directive shall be in effect until revoked.


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


7. I understand that I may revoke this directive at any time.





Signed _________________________________________________

       @001


City of residence: @004

County of residence: @005

State of residence: @006



	The declarant has been personally known to me and
I believe him or her to be of sound mind. I am not related to the
declarant by blood or marriage, nor would I be entitled to any 
portion of the declarant's estate on his decease, nor am I the
attending physician of declarant or an employee of the attending
physician or a health facility in which the declarant is a
patient or any person who has a claim against any portion of the
estate of the declarant upon his decease.


Witness:



__________________________________________________


Witness:




__________________________________________________


Witness: 



__________________________________________________


STATE OF TEXAS

COUNTY OF _______________________


	Before me, the undersigned authority, on this day
personally appeared @001, _________________________________ and
__________________________ and _________________________________
known to me to be the declarant and witnesses whose names are
subscribed to the foregoing instrument in their respective
capacities, and, all of said persons being by me duly sworn, the
declarant @001 declared to me and to the said witnesses in my
presence that the said instrument is his Directive to Physicians,
and that he willingly and voluntarily made and executed it as his
free act and deed for the purposes therein expressed.


Declarant:



___________________________________________________________

@001



Subscribed and acknowledged before me by the said Declarant
@001  and by the said witnesses ___________________________ and
_____________________________ on This ______________ day of
___________________________________________, 19______.



______________________________________________

Notary Public in and for


___________________________  County, Texas