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Create Your Living Will

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Some jurisdictions require that a Living Will be notarized by a Notary Public in order to be valid.

Some jurisdictions require that a Living Will be notarized by a licenced law practitioner (lawyer).

Check with your local authorities.


(1) Name of Declarant
(2) Other Name of Declarant, if any
(3) DATE OF BIRTH
(4) ADDRESS
(5) CITY
(6) STATE COUNTRY

(7) IF REQUIRED DO YOU ACCEPT A BLOOD TRANSFUSION  Yes  No

(8) IF REQUIRED DO YOU ACCEPT AN ORGAN TRANSPLANT  Yes  No

(9) IF RECOVERY IS POSSIBLE USE MAX TREATMENTS  Yes  No

(10) IF RECOVERY IS POSSIBLE USE MID TREATMENTS  Yes  No

(11) IF RECOVERY IS POSSIBLE USE STANDARD TREATMENTS  Yes  No

(12) IF NO RECOVERY IS POSSIBLE USE CARDIAC MASSAGE IF NEEDED  Yes  No

(13) IF NO RECOVERY IS POSSIBLE USE TUBE FEEDING IF NEEDED  Yes  No

(14) IF NO RECOVERY IS POSSIBLE USE MECHANICAL RESPIRATOR IF NEEDED  Yes  No

(15) IF NO RECOVERY IS POSSIBLE KEEP ME COMFORTABLE AND LET ME DIE  Yes  No

(16) Other Instructions, if any

(17) IF NO RECOVERY IS POSSIBLE I WISH TO DIE AT HOME  Yes  No

(18) Date of Declarant Signing
(19) Name of Witness 1
(20) Date of Witness 1 Signing
(21) Address of Witness 1
(22) Telephone Number of Witness 1
(23) Name of Witness 2
(24) Date of Witness 2 Signing
(25) Address of Witness 2
(26) Telephone Number of Witness 2
(27) IF NOTARIZED State of Notarization
(28) IF NOTARIZED County of Notarization
(29) IF NOTARIZED Date of Notarial Seal
(30) Specific Location of the Living Will
(31) Name of Person with copy 1 of Will
(32) Address of Person with copy 1 of Will
(33) Name of Person with copy 2 of Will
(34) Address of Person with copy 2 of Will

Base price:

Regular: $20.00.

 
Email addresses, optional
(to send copy of result)

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