Illinois Living Will Declaration
This document serves as a Living Will, as provided for under the Illinois Living Will Act, for the following individual:
Name: ____________________________________________
Birth Date: ______________________________________
Address: __________________________________________
City/State/Zip: ___________________________________
Phone Number: ____________________________________
In the event that I, _____________________(the above-named individual), suffer from a terminal condition where death is imminent and the application of death-delaying procedures would only serve to prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfortable care or to alleviate pain.
This declaration does not affect the provision of any care necessary to provide comfort care or to alleviate pain.
It is my intention that this declaration 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 of such refusal.
I understand the full import of this declaration, and I am emotionally and mentally competent to make this decision.
Witnesses
The following witnesses affirm that the declarant is known to them, signed this declaration in their presence, and appears to be of sound mind and not under duress, fraud, or undue influence.
- Name: _______________________________________________
- Witness Address: _____________________________________
- City/State/Zip: _______________________________________
- Signature: ___________________________________________
- Date: ________________________________________________
- Name: _______________________________________________
- Witness Address: _____________________________________
- City/State/Zip: _______________________________________
- Signature: ___________________________________________
- Date: ________________________________________________
This Living Will is made voluntarily and in accordance with my desires and in compliance with the laws of the State of Illinois.
Declarant's Signature: ___________________________________
Date: ___________________________________________________