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CALIFORNIA DIRECTIVE TO PHYSICIANS

Directive made this _____ day of __________, 20__.

I, ____________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, do hereby declare:

1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally.

2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

3. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy.

4. If I have been diagnosed and notified at least 14 days ago as having a terminal condition by ___________________, M.D., whose address is

____________________________, and whose telephone number is

_____________________.

I understand that if I have not filled in the physician's name and address, it shall be presumed that I did not have a terminal condition when I made out this directive.

5. This directive shall have no force or effect five years from the date filled in above.

6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

Signed: ____________________________________

City, County and State of Residence: ______________________________

The declarant has been personally known to me and I believe him or her to be of sound mind.

Witness: ____________________________________

Witness: ____________________________________

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