I, __________________________________________ being of sound mind, willfully and voluntarily make known my desire that my life will not be artificially prolonged under the circumstances set forth below, and do hereby declare:
1. Seeing I have chosen the belief of the General Assembly and Church of The Firstborn, in that if at all possible, and I have chosen to do so, I shall trust in God for all my health and healing benefits. I will use prayer, and call for the Elders of the Church, and they shall pray over me, as mentioned in the bible, James 5:14. I will also be able to call for the believers in the church, who can pray over me, as mentioned in St. Mark, 16:18. In doing these things, it is my opinion and my desire, that I shall not have the need for, nor choose any medical attention, nor an attending physician, in case of sickness or death. Because of this, it is my decision to choose this DIRECTIVE to all health care facilities, or authorities in charge, that they follow the instructions set forth in this DIRECTIVE entirely and completely.
2. If at any time I should have an incurable or irreversible condition caused by injury, disease, or illness as reasonable determined to be a terminal condition by two or more of the Elders of the General Assembly and Church of The Firstborn, (or in the absence of Ordained Elders of the local Church, local ministers in charge will serve in their capacity), or an attending physician if I have chosen one, and where the application of life-sustaining procedures would serve only to artificially postpone the moment of my death, and where the attending Elders of the church, or an attending physician, have then determined that my death is imminent or will result within a relatively short time without application of life-sustaining procedures, I direct that those procedures be withheld or withdrawn, and that I be permitted to die naturally and without resuscitation..
3. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this DIRECTIVE shall be honored by my family, my attending ministers of the Church, or attending physicians if used, as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
4. If I have been diagnosed as pregnant and my chosen physician knows that diagnosis, this DIRECTIVE shall have no effect during the course of my pregnancy.
5. This DIRECTIVE shall be in effect until it is revoked.
6. I understand the full import of this DIRECTIVE and I am emotionally and mentally competent to make this DIRECTIVE.
7. I understand that I may revoke this DIRECTIVE at any time. Page 1.
8. If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions, which can be given effect without the invalid provision, and to this end the directions in this document are severable. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.
9.
I understand that some states do allow me to designate another
person to make treatment decisions for me if I should become comatose,
incompetent or otherwise mentally or physically incapable of communication.
But if the laws of the state, which I am in, do allow me to do so, it is my
desire to designate the following person,
__________________________________ __________________
address_______________________________________________________
as the person to make such treatment decisions for me if I should become
incapable of communication with my chosen physician, or the attending Elders or
Ministers present.
If the person I have named above is unable to act on my behalf, I authorize the
following person to do so:
_________________________________________ ______________
address_______________________________________________________
I have discussed my wishes with these persons and trust their judgment.
10. Other directions: All life-sustaining measures, including nutrition and hydration, will be withheld unless I have listed different instructions in the space below;
Date:______________________
Declarant Signature:________________________________________
Address:________________________________________________________
City:____________________________ State:____ ___ Zip
Page 2.
Two witnesses must sign the DIRECTIVE in the spaces provided below, (Notarization not necessary in all states.)
I am not related to the declarant by blood or marriage; nor am I the chosen attending physician of the declarant or an employee of the chosen attending physician; nor am I a patient in the health care facility in which the declarant is a patient, or an Elder of the General Assembly and Church of The Firstborn, or a local Minister in charge, or any person who has a claim against any portion of the estate of the declarant upon his/her decease. Furthermore, if I am an employee of a health facility in which the declarant is a patient, I am not involved in providing direct patient care to the declarant nor am I directly involved in the financial affairs of the health facility.
Witness:_______________________ ______________________ _______
Address:_____________________________________________ _______
Phone:_______ ____________________________
Witness:________________ _____________________________ _______
Address:______________________________ _______________ _______
Phone:______________________________________________________
Notary
The Declarant, whose signature appears on page 2, is known to me, is eighteen
years of age or older, of sound mind and voluntarily signed this document in my
presence. I am eighteen years of age or older.
Signed this _______Day of __________, 20_____
______________________________________
Notary Signature
End of Document Page 3.