TO MY FAMILY, MY PHYSICIAN, MY CLERGYMAN, TO ANY MEDICAL FACILITY IN WHOSE CARE I HAPPEN TO BE, TO ANY INDIVIDUAL WHO MAY BECOME RESPONSIBLE FOR MY HEALTH, WELFARE OR AFFAIRS.

Be it known that I _________________________________________________________________ of the Borough ______________________, County of ____________________________ and State of ______________________________, wish it made known that if the situation arises in which there is no reasonable expectation for recovery from physical or mental disability, I request that I be allowed to die and that I not be kept alive by artificial means or "heroic measures". Specifically I do not wish to be tube fed. I do not fear death as much as I do the indignities of deterioration, dependence and hopeless pain. I therefore request that medication be mercifully administered to alleviate suffering even though this may hasten the moment of my death.

This request is made after careful consideration. It is my wish that those caring for me feel morally bound to follow its mandate. I recognize that this places a heavy responsibility upon you, but it is my intention of relieving you of such a responsibility and of placing it upon myself in accordance with the strong conviction with which this request is made.

IN WITNESS THEREOF, I _______________________________________________, have here unto set my hand and seal this date: ____________________________________.

Name: _______________________________________________________________________________

Witness ________________________________________________________________

Witness ________________________________________________________________

Copies of this request have been given to:

_____________________________________________________

_____________________________________________________

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