#5850
@001 Please enter the name of the declarant:
@002 Please enter the name of "attorney":
@003 Please enter the City of of residence of declarant:
@004 Please enter the county of residence of declarant:
@005 Please enter the state of residence of declarant: 
#end control section
#5850
/* PARA. 5850: Wyoming Living Will */
STATUTORY DECLARATION IN CONFORMANCE WITH WYOMING LIVING WILL
LAW, WYOMING STATUTES 35-22-102


           DECLARATION OF @001



	Declaration made this __________ day of ________________


19________. I, @001, being of sound mind, willfully and
voluntarily make known my desires 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 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withheld or withdrawn, and that I be permitted to die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.


	If, in spite of this declaration, I am comatose or
otherwise unable to make treatment decisions for myself, I 
HEREBY designate @002 to make treatment decisions for me.


	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: @003


County of residence: @004


State of Residence: @005





 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 declaration of
the declarant. I am not related to the declarant by blood
or marriage, entitled to any portion of the estate of the
declarant according to the laws of intestate succession or
under any will of declarant or codicil thereto, or directly
financially responsible for declarant's medical care.



Witness 	_____________________________________________





Witness         _____________________________________________


Date: _____________________