Declaration of a Desire for a Natural Death as Provided by North Carolina G.S. 90-321
I, ________________, being of sound mind, desire that my life not be prolonged by extraordinary means if my condition is determined to be terminal and incurable. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means.
This the ______________ day of ___________________ 20___.
________________________________________________
SIGNATURE
I hereby state that the Declarant, ________________, being of sound mind signed the above declaration in my presence and that I am not related to the Declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the Declarant, under any existing will or codicil of the Declarant, or as an heir under the Interstate Succession Act if the Declarant died on this date without a will. I also state that I am not the Declarant’s attending physician or an employee of the Declarant’s attending physician or an employee of a health facility in which the Declarant is a patient or an employee of a nursing home or any group-care home where the Declarant resides. I further state that I do not now have any claim against the Declarant.
Witness
____________________________________________________________
Witness
____________________________________________________________
CERTIFICATE
I, _____________________________________________(state if Clerk of Superior Court or Deputy Clerk or Notary Public) for _________________________________ County, hereby certify that ________________, the Declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his Declaration Of A Desire for A Natural Death, and that he willingly and voluntarily made and executed it as his free act and deed for the purposes expressed in it, I further certify that __________________________________ and
__________________________ witnesses, appeared before me and swore that they witnessed ________________, Declarant, sign the attached declaration, believing him to be of a sound mind; and also swore that at the time they witnessed the declaration (i) they were not elated within the third degree to the Declarant or to the Declarant’s spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the Declarant upon the Declarant’s death under any will of the Declarant or codicil thereto then existing or under the Interstate Succession Act as it provides at that time, and (iii) they were not a physician attending the Declarant or an employee of an attending physician or an employee of a health facility in which the Declarant was a patient or an employee of a nursing home or any group-care home in which the Declarant resided, and (iv) they did not have a claim against the Declarant.
I further certify that I am satisfied as to the genuineness and due execution of the declaration. This the _________ of ______________, 20______.
________________________________________________
Title: ____________________________________
County of _____________
Declaration of a Desire for a Natural Death as Provided by North Carolina G.S. 90-321
Review List
This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in North Carolina. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.
- Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.
________________________________________________________________________________
Get more Free Credit Repair Templates and Business Plans Form at Business Plan Software