Life Sustaining Statute, New Hampshire

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Statutory Declaration in Conformance with New Hampshire Terminal Care Document Law, N.H. R.S. 137-H: 3

DECLARATION OF ___________________

Declaration made this __________ day of ________________ 20____. I ________________, 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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide me with comfort care.

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.

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Signature

State of _______________

_________ County

We, the Declarant and the witnesses, being duly sworn each declare to the notary public or justice of the peace or other official signing below as follows:

1. The Declarant signed the instrument as a free and voluntary act for the purposes expressed, or expressly directed another to sign for him.

2. Each witness signed at the request of the Declarant, in his presence, and in the presence of the other witness.

3. To the best of my knowledge at the time of the signing the Declarant was at least 18 years of age, and was of sane mind and under no constraint or undue influence.

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Declarant

________________________________________________

Witness

________________________________________________

Witness

Sworn to and signed before me by ____________ Declarant, and ___________________________ witnesses on _____________________, 20____.

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Signature

Official Capacity: _____________________