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Download "Living Will" - Maryland

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Maryland Living Will
I, _______________________________ with a mailing address of ______________
____________________________________________________________________,
being of sound mind, memory, disposition, understanding, and at least eighteen years
of age, do willfully and freely, by this Living Will, direct my family, physician(s),
attorney, and any other individuals who may in the future become responsible for my
health and well-being and any resolutions related thereto, whether partly or fully, to
take the following actions in each of the circumstances described in this Living Will
below.
1. If I develop a condition deemed to be “terminal” with my attending physician
and one other medical professional both agreeing within a reasonable degree of
medical certainty that I cannot be cured, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. If I fall into a coma with my attending physician and one other medical
professional both agreeing within a reasonable degree of medical certainty that
there is no chance for recovery, I direct the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. If I develop a persistent vegetative state with my attending physician and one
other medical professional both determining within a reasonable degree of
medical certainty that there is no chance for recovery, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Maryland Living Will
I, _______________________________ with a mailing address of ______________
____________________________________________________________________,
being of sound mind, memory, disposition, understanding, and at least eighteen years
of age, do willfully and freely, by this Living Will, direct my family, physician(s),
attorney, and any other individuals who may in the future become responsible for my
health and well-being and any resolutions related thereto, whether partly or fully, to
take the following actions in each of the circumstances described in this Living Will
below.
1. If I develop a condition deemed to be “terminal” with my attending physician
and one other medical professional both agreeing within a reasonable degree of
medical certainty that I cannot be cured, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. If I fall into a coma with my attending physician and one other medical
professional both agreeing within a reasonable degree of medical certainty that
there is no chance for recovery, I direct the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. If I develop a persistent vegetative state with my attending physician and one
other medical professional both determining within a reasonable degree of
medical certainty that there is no chance for recovery, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
4. In addition to the directions I have listed on this Living Will, I also want the
following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Signatures
Principal
By signing this Living Will in front of the witnesses named below, I hereby execute
and subscribe to the statements made in this Living Will both freely and voluntarily,
and wholeheartedly request that my family, physician(s), attorney, and any other
individuals who may in the future become responsible for my health and well-being
and any decisions related thereto, whether partly or fully, all abide by my wishes as
pronounced herein.
_________________________________
Name
_________________________________
Signature
_________________________________
Date of signing
Witnesses
This Living Will was signed by _________________________________ in the
presence of the following two witnesses, who by their signatures below, confirm that
_________________________________ was, at the time this document was signed,
at least eighteen years of age, of sound mind, memory, disposition, understanding, not
under any improper influence and able to understand the weight of this decision. The
undersigned have subscribed this document in the presence of each other and
_________________________________ and at their request.
First Witness: ​ _ ________________________________ ​ w ith a mailing address of
____________________________________________________________________.
_________________________________
Signature
_________________________________
Date of signing
Second Witness: ​ _ ________________________________ ​ w ith a mailing address of
____________________________________________________________________.
_________________________________
Signature
_________________________________
Date of signing
Notary Acknowledgement
STATE OF MARYLAND
COUNTY OF _________________________________
I, _________________________________, a Notary Public of said County, do certify
that _________________________________, as Principal, and __________________
________________ and _________________________________, as witnesses,
whose names are signed to the writing above bearing date on the _______ day of
______________, ______, have this day acknowledged the same before me.
Given under my hand this _______ day of ______________, ______.
My commission expires: ___________________________________
______________________________________
Signature of Notary Public