Wampum

LIVING WILL

Living will made this ______ day of ______________ (month, year).

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

1. If at any time I should (check each option desired):

( ) have a terminal condition,

( ) become in a coma with no reasonable expectation of
regaining consciousness, or

( ) become in a persistent vegetative state with no reasonable
expectation of regaining significant cognitive function,

as defined in and established in accordance with the procedures
set forth in paragraphs (2), (9), and (13) of Code Section
31-32-2 of the Official Code of Georgia Annotated, I direct that
the application of life-sustaining procedures to my body (check
the option desired):
( ) including nourishment and hydration,

( ) including nourishment but not hydration, or

( ) excluding nourishment and hydration,

be withheld or withdrawn and that I be permitted to die;

2. In the absence of my ability to give directions regarding the
use of such life-sustaining procedures, it is my intention that
this living will 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. I understand that I may revoke this living will at any time;

4. I understand the full import of this living will, and I am at
least 18 years of age and am emotionally and mentally competent
to make this living will; and

5. If I am a female and I have been diagnosed as pregnant, this
living will shall have no force and effect unless the fetus is
not viable and I indicate by initialing after this sentence that
I want this living will to be carried out. _________(Initial)

Signed ______________

____________(City), __________(County), and __________(State of
Residence).

I hereby witness this living will and attest that:

(1) The declarant is personally known to me and I believe the
declarant to be at least 18 years of age and of sound mind;

(2) I am at least 18 years of age;

(3) To the best of my knowledge, at the time of the execution of
this living will, I:

(A) Am not related to the declarant by blood or marriage;

(B) Would not be entitled to any portion of the declarant's
estate by any will or by operation of law under the rules of
descent and distribution of this state;

(C) Am not the attending physician of declarant or an employee
of the attending physician or an employee of the hospital or
skilled nursing facility in which declarant is a patient;

(D) Am not directly financially responsible for the
declarant's medical care; and

(E) Have no present claim against any portion of the estate of
the declarant;

(4) Declarant has signed this document in my presence as above
instructed, on the date above first shown.
Witness _______________________

Address _______________________

Witness _______________________

Address _______________________

Additional witness required when living will is signed in a
hospital or skilled nursing facility.

I hereby witness this living will and attest that I believe the
declarant to be of sound mind and to have made this living will
willingly and voluntarily.

Witness: ___________________________
Medical director of skilled
nursing facility or staff
physician not participating
in care of the patient or
chief of the hospital
medical staff or staff
physician or hospital
designee not participating
in care of the patient."