West Virginia Living Will Form

Residents of the State of Virginia can complete this form to establish a valid living will.Download

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Health Care Power of Attorney 
 
  6. I give a durable power of attorney to ____________________ to make 
decisions for m e, consistent with my living will, about medical treatment, 
including the withholding or withdrawal of medical treatment, in the event 
that my treating physician determines I have lost the mental capacity to 
make such decisions for myself. 
  Date: ____________________ 
      _________________________________ 
      Signature 
 
Printed name:_________________________________________________ 
 
Address:_____________________________________________________ 
           street address                        city       state 
 
 
  Statement of Witnesses 
 
  The maker of this living will (the "declarer") signed it in my presence.  He 
or she has been personally known to me and I believe him or her to be 
capable of making health care decisions, to understand this living will, and 
to have signed it voluntarily.  I am not related by blood or marriage to the 
declarer, and I am not now entitled to receive any portion of the declarer's 
estate, either by will or by operation of law, or as a result of any claim 
against the declarer.  I am not the declarer's attending physician or an 
employee of that physician or of a health facility in which the declarer is a 
patient. 
 
  Date: ____________________ 
 
Witness: ____________________________________________________ 
                 Signature/    Address 
 
Witness: ____________________________________________________ 
                 Signature/    Address 
 
 
 
 
[See Revised Code of Washington 70.122.030]  [CLS 9/02]  
 
 
 
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