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Louisiana Living Will Form

To establish a living will in the State of Louisiana, interested individual should execute this form. A living will authorizes the cessation of medical treatments should the individual become afflicted by an incurable condition.Download

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STATE OF LOUISIANA	 	 	
DECLARATION 	
Rev. Oct. 2005 
  
 	
Declaration made this ________day of _______________,   __________ (month, year). 
 
  I,                                                                                                            	
, being of sound 
mind, willfully and voluntarily make known my desire that my dying shall not be artificially 
prolonged under the circumstances set forth below and do hereby declare: 
 
  If at any time I should have an incurable injury, disease or illness, or be in a continual 
profound comatose state with no reasonable chance of recovery, certified to be a terminal and 
irreversible condition by two physicians who have personally examined me, one of whom shall 
be my attending physician, and the physicians have determined that my death will occur whether 
or not life-sustaining procedures are utilized and where the application of life-sustaining 
procedure would serve only to prolong artificially the dying process, I direct (initial one only): 
 
  _______ That all life-sustaining procedures, including nutrition and hydration, be 
withheld or withdrawn so that food and water will not be administered invasively. 
 
  _______ That life-sustaining procedures, except nutrition and hydration, be withheld or 
withdrawn so that food and water can be administered invasively. 
 
  I further direct that I be permitted to die naturally with only the administration of 
medication or the performance of any medical procedure deemed necessary to provide me with 
comfort care. 
 
  In the absence of my ability to give directions regarding the use of such life-sustaining 
procedures, it is my intention that this declaration 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. 
 
  I understand the full import of this declaration and I am emotionally and mentally 
competent to make this declaration. 
     Signed _________________________________________ 
             
    City, Parish, and State of Residence __________                                                               	
 
                                                       
  The declarant has been personally known to me and I believe him or her to be of sound 
mind. 
 
 Witness_____________________________                 Witness___________________________ 	
“LIVING WILL” DECLARATION 
(R.S. 40:1299.58.1 - 40:1299.58.10) 	
INSTRUCTIONS:  Per R.S. 40:1299.58.3(D), the Secretary of State’s Office has established a registry in which 
a person, or his attorney, if authorized by the person to do so, may register the original, multiple original, or a 
certified copy of the declaration.  The filing fee is $20.00 to register the Declaration and receive a laminated 
identification card and ID bracelet.  The filing fee for a revocation is $5.00.  If a certified copy is requested from 
this office, there is an additional fee of $10.00.  Mail the declaration, with the filing fee, to:  Secretary of State, 
Attn: Publications, P.O. Box 94125, Baton Rouge, LA 70804-9125	.
Next: Louisiana Rule to Show Cause Article 103 Form Previous: Louisiana Name Change Petition Form
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