Life Sustaining Statute, Alaska

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Declaration as Provided by Alaska Statutes, Section 18.12.010: Life Sustaining Declaration

DECLARATION of ______________

If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by administration of life- sustaining procedures.

If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain.

I do [] do not [] desire that nutrition or hydration (food and water) be provided by gastric tube or intravenously if necessary.

Signed this______ day of _____________________, 20____.

Signature:

________________________________________________________________

Place of signing: _____________________

The Declarant is known to me and voluntarily signed or voluntarily directed another to sign this document in my presence.

Witness:

________________________________________________________________

Signature

Address:

________________________________________________________________

Signature

Address:

State of _________________________

__________________________________ Judicial District

The foregoing instrument was acknowledged before me this ______ day of _____________________, 20____ by ___________________.

_________________________________________

Signature of person taking acknowledgment