This declaration is made by me (full name) ...................................................

I.D. Number: ..........................................................................................................

Address: ................................................................................................................

.................................................................................................................................

If the time comes when I can no longer take part in decisions for my own future, let this declaration stand as the testament to my wishes.

If there is no reasonable prospect of my recovery from physical illness or impairment in which I am suffering continual pain or am incapable of ever again living a rational existence and when I am no longer capable of being consulted regarding my wishes, I request that I be allowed to die with dignity and not be kept alive by artificial means. I request that they administer whatever drugs necessary to keep me comfortable during this period even if it may reduce the length of my life.

This form is signed and dated by me in the presence of the two undersigned witnesses who at my request in my presence have given their names as witnesses.