Life Sustaining Statute, Montana

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Declaration as Provided by Montana Stats. 50-9-104

DECLARATION

If I should have an incurable or irreversible condition that will cause my death within a reasonable 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 freedom from pain. It is my intention that this declaration shall be valid until revoked by me.

Signed this ___________________ day of ______________

________________________________________________________________

Signature: ______________

City of residence: __________________

County of residence: ________________

State of residence: _________________

The Declarant is known to me and voluntarily signed this document in my presence.

Witness:

_____________________________________________________________

Witness:

_____________________________________________________________