DECLARATION


     I, _____________________________, being of sound mind, 
willfully and voluntarily make this declaration to be followed 
if I become incompetent.  This declaration reflects my firm and 
settled commitment to refuse life-sustaining treatment under the 
circumstances indicated below.

     I direct my attending physician to withhold or withdraw 
life-sustaining treatment that serves only to prolong the 
process of my dying, if I should be in a terminal condition or 
in a state of permanent unconsciousness.

     I direct that treatment be limited to measures to keep me 
comfortable and to relieve pain, including any pain that might 
occur by withholding or withdrawing life-sustaining treatment.

     In addition, if I am in the condition described above, I 
feel especially strongly about the following forms of treatment:

          I ( ) do ( ) do not want cardiac resuscitation.
          I ( ) do ( ) do not want mechanical respiration.
          I ( ) do ( ) do not want tube feeding or any other 
               artificial or invasive form of nutrition (food) 
               or hydration  (water).
          I ( ) do ( ) do not want blood or blood products.
          I ( ) do ( ) do not want any form of surgery or 
               invasive diagnostic tests.
          I ( ) do ( ) do not want kidney dialysis.
          I ( ) do ( ) do not want antibiotics.

I realize that if I do not specifically indicate my preference
regarding any of the forms of treatment listd above, I may
receive that form of treatment.

     Other instructions:

     I ( ) do ( ) do not want to designate another person as my 
surrogate to make medical treatment decisions for me if I should 
be incompetent and in a terminal condition or in a state of 
permanent unconsciousness.

    Name and address of surrogate  (if applicable):



    Name and address of substitute surrogate (if surrogate 
designated above is unable to serve):



     I made this declaration on __________________, 19___.

            Declarant's signature: ____________________________

              Declarant's address: ____________________________
                                   ____________________________


     The declarant knowingly and voluntarily signed this writing 
by signature or mark in my presence.

____________________________     ______________________________
Signature of Witness             Address of Witness


____________________________     ______________________________
Signature of Witness             Address of Witness