Your Living Will . Com
Explanation of YourLivingWill.com

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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.


                        YOURLIVINGWILL.COM

YOUR LIVING WILL IS A DOCUMENT YOU WRITE SO THAT YOU MAY FORMULATE YOUR WISHES IN CASE OF A SEVERE DISEASE WHEN YOU MAY NOT BE ABLE TO THINK OR SAY WHAT YOU WOULD LIKE DONE TO YOU .

YOU EXPECT YOUR DOCTORS/THE HEALTH CENTER WHERE YOU ARE HOSPITALIZED AND ALL INVOLVED IN YOUR CARE TO COMPLY WITH YOUR WISHES . ------------------------------------------------------------------------------- 1-FIRST YOU ANSWER BASIC IDENTIFICATION DATA Name of Declarant Other Name of Declarant, if any DATE OF BIRTH ADDRESS CITY STATE COUNTRY ------------------------------------------------------------------------------- 2-YOU MUST ANSWER BASIC QUESTIONS REGARDING SPECIFIC SITUATIONS: PERSONS FOR VARIOUS REASONS MAY REFUSE BLOOD TRANSFUSIONS OR ORGAN TRANSPLANTS , IT IS IMPORTANT THAT THESE WISHES BE KNOWN . IF REQUIRED DO YOU ACCEPT A BLOOD TRANSFUSION (Y/N) IF REQUIRED DO YOU ACCEPT AN ORGAN TRANSPLANT (Y/N) ------------------------------------------------------------------------------- 3- IF YOU ARE IN A SEVERE BUT REVERSIBLE PHYSICAL OR MENTAL CONDITION (THERE IS A REASONABLE ANTICIPATION OF RECOVERY) WHAT LEVEL OF TREATMENT WOULD YOU LIKE TO RECEIVE ? ANSWER THESE 3 QUESTIONS A-USE THE MAXIMUM AVAILABLE MEDICAL AND SURGICAL HELP EVEN NEW AND EXPERIMENTAL TREATMENTS OR "HEROIC MEASURES" (Y/N)

B-USE THE MAXIMUM AVAILABLE MEDICAL MEDICAL AND SURGICAL HELP EXCLUSIVE OF EXPERIMENTAL TREATMENTS OR "HEROIC MEASURES" (Y/N)

C-USE CONSERVATIVE STANDARD MEDICAL/SURGICAL TREATMENTS (Y/N) ------------------------------------------------------------------------------- 4- THE FOLLOWING WISHES APPLY IF YOU ARE IN AN INCURABLE OR IRREVERSIBLE MENTAL OR PHYSICAL CONDITION AND THERE IS NO REASONABLE ANTICIPATION OF RECOVERY FROM SEVERE PHYSICAL OR MENTAL INCAPACITY :

A-IF YOUR HEART STOPS ELECTRICAL OR MECHANICAL RESUSCITATION OF YOUR HEART SHOULD BE PERFORMED . (Y/N)

B-IF YOU ARE PARALYZED OR CANNOT FEED YOURSELF NASOGASTRIC TUBE FEEDING SHOULD BE USED (Y/N)

C-WHEN YOU ARE NO LONGER ABLE TO BREATHE ON YOUR OWN MECHANICAL OR ASSISTED RESPIRATION SHOULD BE USED (Y/N)

D-YOU SHOULD BE PERMITTED TO DIE AND YOU DO NOT WANT TO BE KEPT ALIVE BY MEDICATIONS, ARTIFICIAL MEANS, OR SO-CALLED "HEROIC MEASURES." YOU REQUEST AND DIRECT THAT TREATMENT, INCLUDING MEDICATION, WATER AND FLUIDS BE MERCIFULLY ADMINISTERED TO YOU TO ALLEVIATE PAIN AND SUFFERING SO AS TO KEEP YOU COMFORTABLE EVEN THOUGH THIS MAY SHORTEN YOUR REMAINING LIFE. (Y/N)

E-YOU ALSO EXPRESS THE FOLLOWING SPECIFIC WISHES HERE YOU ENTER MANUALLY ALL OTHER SPECIFIC WISHES YOU MAY HAVE . ------------------------------------------------------------------------------- 5- IMPORTANT CAVEAT REGARDING YOUR INSTRUCTIONS: THESE INSTRUCTIONS ARE SET FORTH AFTER CAREFUL THOUGHT AND ARE IN ACCORDANCE WITH YOUR CLEAR CONVICTIONS AND BELIEFS. YOU WANT THE WISHES AND DIRECTIONS HERE EXPRESSED CARRIED OUT TO THE EXTENT PERMITTED BY LAW UNLESS YOU HAVE RESCINDED THEM IN A NEW WRITING OR BY CLEARLY INDICATING THAT YOU HAVE CHANGED YOUR MIND. THOSE CONCERNED WITH YOUR HEALTH AND WELFARE ARE SPECIFICALLY ASKED TO TAKE WHATEVER ACTION NECESSARY, INCLUDING LEGAL ACTION, TO REALIZE YOUR WISHES AND INSTRUCTIONS. YOU HOPE THAT THOSE TO WHOM THIS DOCUMENT IS DIRECTED WILL REGARD THEMSELVES AS MORALLY BOUND TO ABIDE BY ITS CONTENTS IF AND TO THE EXTENT THAT THE PROVISIONS OF THIS DOCUMENT ARE NOT LEGALLY ENFORCEABLE. IN OTHER WORDS YOU ALLOW YOURSELF TO CHANGE OR ALTER ALL OF THIS DOCUMENT VERBALLY AT ANY TIME SHOULD YOU EVER CHANGE YOUR MIND. YOU ALSO ASK ALL INVOLVED TO STRIVE TO ABIDE BY YOUR WISHES . ------------------------------------------------------------------------------- 6- YOU WOULD LIKE TO LIVE OUT YOUR LAST DAYS AT HOME RATHER THAN IN A HOSPITAL IF IT IS POSSIBLE . (Y/N) ------------------------------------------------------------------------------- 7- YOU MUST SIGN THE DOCUMENT AND DATE IT ------------------------------------------------------------------------------- 8- OPTIONALLY YOU MAY HAVE 1 OR 2 WITNESSES TO YOUR SIGNATURE IF SO:

NAME OF WITNESS 1 : .................. DATE: ADDRESS OF WITNESS 1 :..................................... PH. NO. OF WITNESS 1 :.................

NAME OF WITNESS 2 : .................. DATE: ADDRESS OF WITNESS 2 :..................................... PH. NO. OF WITNESS 2 :.................. ------------------------------------------------------------------------------- 9- OPTIONALLY YOU MAY WISH TO SIGN THIS LIVING WILL IN FRONT OF A PUBLIC NOTARY ANS SO HAVE IT NOTARIZED:THE FORM THEN BECOMES:

STATE OF .....................COUNTY OF................... :

ON................ BEFORE ME PERSONALLY CAME.....(YOUR NAME)........ TO ME KNOWN, AND KNOWN TO ME TO BE THE INDIVIDUAL DESCRIBED IN AND WHO EXECUTED THE FOREGOING LIVING WILL, AND DULY ACKNOWLEDGED TO ME THAT (S)HE EXECUTED THE SAME.

................................ NOTARY PUBLIC ------------------------------------------------------------------------------- 10- LOCATION OF THIS ORIGINAL LIVING WILL:HERE YOU INDICATE WHERE YOU KEEP THE ORIGINAL OF THIS LIVING WILL VG. ADDRESS AND EXACT PLACE WHERE THE DOCUMENT IS LOCATED AGAIN THIS IS OPTIONAL ------------------------------------------------------------------------------- 11- OPTIONALLY COPIES OF YOUR LIVING WILL MAY BE LEFT IN THE HANDS OF NAMED PERSONS OR INSTITUTIONS (1 OR 2) IF SO IDENTIFY THESE PERSONS AND GIVE THEIR ADDRESSES SO THAT THEY MAY BE REACHED AND PRESENT YOUR LIVING WILL SO THAT IT MAY BE EXECUTED: (AGAIN THIS IS OPTIONAL)

NAME OF PERSON 1 :...................................... ADDRESS OF PERSON 1:.......................................

NAME OF PERSON 2 :...................................... ADDRESS OF PERSON 2:....................................... ------------------------------------------------------------------------------- 12 WHEN YOURLIVINGWILL.COM PRODUCES THIS DOCUMENT A SPECIFIC FILE NUMBER IS GIVEN TO YOUR DOCUMENT AND IT BECOMES ARCHIVED AND REGISTERED IN THE DATABASE OF YOURLIVINGWILL.COM . USING THE PROPER ID NUMBER AND PASSWORD THIS DOCUMENT CAN BE EDITED OR MODIFIED 24 HOURS A DAY BY ACCESSING THE WEB SITE OF YOURLIVINGWILL.COM AND AT NO COST. THE DOCUMENT IS ALSO DATED AT THE TIME OF ITS ORIGINAL CREATION OR AT THE TIME OF ITS REVISION BY YOU BUT REMEMBER ONLY YOU CAN CHANGE THIS DOCUMENT.

ONE OF THE MAJOR ADVANTAGES OF YOURLIVINGWILL.COM IS THAT YOU HAVE A LIVING WILL THAT IS STORED IN A NEUTRAL SAFE ENVIRONMENT ACCESSIBLE WITHIN SECONDS 24 HOURS A DAY.

YOU MAY HAVE A CARD CONTAINING THE WEB ADDRESS OF YOURLIVINGWILL.COM WITH YOUR ID NUMBER AND YOUR ACCESS CODE

WITH THE DATA ON THIS CARD MEDICAL PERSONEL IN CASE OF EMERGENCY MAY HAVE ACCESS TO LIVING WILL INSTANTANEOUSLY.

THIS SERVICE IS PROVIDED TO YOU FOR $9.95 PER MONTH BILLED TO YOUR CREDIT CARD. YOU MAY CANCEL ANYTIME BY CALLING US OR EMAILING US.

IF YOU CHOOSE TO HAVE YOUR LIVING WILL NOTARIZED PRINT IT HAVE IT NOTARIZED AND SEND US A HARD COPY OF THE NOTARIZED LIVING WILL WE WILL KEEP IT FOR YOU AT NO EXTRA COST. 1999/04/15 -------------------------------------------------------------------------------



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