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MISSOURI LIVING WILL DECLARATION I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging 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 medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying. Signed this _____ day of ______________, 20_____. ________________________________ ________________________________ Printed Name of Declarant Signature of Declarant Address: ____________________________________________ ____________________________________________ WITNESSETH The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence. Witness #1: Witness #2: ________________________________ ________________________________ Signature Signature ________________________________ ________________________________ Printed Name Printed Name ________________________________ ________________________________ Address, Line 1 Address, Line 1 ________________________________ ________________________________ Address, Line 2 Address, Line 2 REVOCATION PROVISION I hereby revoke the above declaration. ________________________________ ________________________________ Printed Name of Declarant Signature of Declarant Date: ________________ Other Forms You May Need * Missouri General Durable Power of Attorney for Property & Finances (Upon Disability) * Missouri General Durable Power of Attorney for Property & Finances (Immediate)click to download Missouri Living Will template
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