Living Will
DECLARATION
This declaration is made this __________ day of__________________________ (month, year).
I, ___________________________________, born on _____________, being of sound mind,
willfully and voluntarily make known my desires that my moment of death shall not be
artificially postponed.
If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a
terminal condition by my attending physician who has personally examined me and has
determined that my death is imminent except for death delaying procedures, I direct that such
procedures which would only prolong the dying process be withheld or withdrawn, and that I be
permitted to die naturally with only the administration of medication, sustenance, or the
performance of any medical procedure deemed necessary by my attending physician to provide
me with comfort care.
In the absence of my ability to give directions regarding the use of such death delaying
procedures, it is my intention that this declaration shall be honored by my family and physician
as the final expression of my legal right to refuse medical or surgical treatment and accept the
consequences from such refusal.
Signed________________________________________________________________________
City, County and State of Residence________________________________________________
The declarant is personally known to me and I believe him or her to be of sound mind. I saw the
declarant sign the declaration in my presence (or the declarant acknowledged in my presence that
he or she had signed the declaration) and I signed the declaration as a witness in the presence of
the declarant. I did not sign the declarant’s signature above for or at the direction of the
declarant. At the date of this instrument, I am not entitled to any portion of the estate of the
declarant according to the laws of intestate succession or, to the best of my knowledge and
belief, under any will of declarant or other instrument taking effect at declarant’s death, or
directly financially responsible for declarant’s medical care.
Witness _______________________________________________________________________
Witness _______________________________________________________________________
History
(Source: P.A. 85-1209.)
Annotations
Note. This section was Ill.Rev.Stat., Ch. 110 1/2, Para. 703.
Rev 5/2012
Living Will
DECLARATION
This declaration is made this __________ day of__________________________ (month, year).
I, ___________________________________, born on _____________, being of sound mind,
willfully and voluntarily make known my desires that my moment of death shall not be
artificially postponed.
If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a
terminal condition by my attending physician who has personally examined me and has
determined that my death is imminent except for death delaying procedures, I direct that such
procedures which would only prolong the dying process be withheld or withdrawn, and that I be
permitted to die naturally with only the administration of medication, sustenance, or the
performance of any medical procedure deemed necessary by my attending physician to provide
me with comfort care.
In the absence of my ability to give directions regarding the use of such death delaying
procedures, it is my intention that this declaration shall be honored by my family and physician
as the final expression of my legal right to refuse medical or surgical treatment and accept the
consequences from such refusal.
Signed________________________________________________________________________
City, County and State of Residence________________________________________________
The declarant is personally known to me and I believe him or her to be of sound mind. I saw the
declarant sign the declaration in my presence (or the declarant acknowledged in my presence that
he or she had signed the declaration) and I signed the declaration as a witness in the presence of
the declarant. I did not sign the declarant’s signature above for or at the direction of the
declarant. At the date of this instrument, I am not entitled to any portion of the estate of the
declarant according to the laws of intestate succession or, to the best of my knowledge and
belief, under any will of declarant or other instrument taking effect at declarant’s death, or
directly financially responsible for declarant’s medical care.
Witness _______________________________________________________________________
Witness _______________________________________________________________________
History
(Source: P.A. 85-1209.)
Annotations
Note. This section was Ill.Rev.Stat., Ch. 110 1/2, Para. 703.
Rev 5/2012