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Kentucky our attorney. -2- c or other officer. Date commission expires:________________________ Execution of this document restricts withholding and withdrawing of some medical procedures. Consult Kentucky Revised Statutes or y and signed this writing or directed it to be signed and dated as above. Done this ________________ day of __________, 20____ ________________________________________________ Signature of Notary PubliATE OF KENTUCKY) ______________.County) Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18) years of age, or older, and acknowledged that he voluntarily dated________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ OR STed this writing or directed it to be dated and signed for the grantor. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______ddress: __________________________________________________________________ In our joint presence, the grantor, who is of sound mind and eighteen (18) years of age, or older, voluntarily dated and signI am emotionally and mentally competent to make this directive. Signed this ____________ day of ____________ 20_____ -1- Signed: ____________________________________________________________________ Ad as pregnant and that diagnosis is known to my attending physician, this directive shall have no force or effect during the course of my pregnancy. I understand the full import of this directive and surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of the refusal. If I have been diagnose regarding the use of life-prolonging treatment and artificially provided nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family, and anyany part of my body upon death for any purpose specified in KRS 311.185. _________ DO NOT authorize the giving of all or any part of my body upon death. In the absence of my ability to give directions, or other treatment if the surrogate determines that withholding or withdrawing is in my best interest; but I do not mandate that withholding or withdrawing. _________ Authorize the giving of all or ally provided food, water, or other artificially provided nourishment or fluids. _________ Authorize my surrogate, designated above, to withhold or withdraw artificially provided nourishment or fluidsAuthorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids. _________ DO NOT authorize the withholding or withdrawal of artificiinistration of medication or the performance of any medical treatment deemed necessary to alleviate pain. _________ DO NOT authorize that life-prolonging treatment be withheld or withdrawn. _________ oked. The following are my directions and wishes as indicated below by my initials: _________ Direct that treatment be withheld or withdrawn, and that I be permitted to die naturally with only the admnently unconscious have been indicated by checking and initialing the appropriate lines below. By checking and initialing the appropriate lines, I specifically state that: Any prior Living Will is revMy wishes regarding life-prolonging treatment and artificially provided nutrition and hydration to be provided to me if I no longer have decisional capacity, have a terminal condition, or become perma out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -2- Living Will ve an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should ha to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time tohe fourth degree of consanguinity or affinity or a member of the same religious order. -1- [_] These forms are provided "as is" and no implied or express warranties have been made or are provided ason. (4) An employee, owner, director, or officer of a health care facility where the grantor is a resident or patient shall not be designated or act as surrogate unless related to the grantor within ten notice to the grantor; to the immediate successor surrogate, if any; to the attending physician; and to any health care facility which is then waiting for the surrogate to make a health care decisirantor; or (e) Any person directly financially responsible for the grantor's health care. (3) A person designated as a surrogate pursuant to an advance directive may resign at any time by giving writtstribution statutes of the Commonwealth; (c) An employee of a health care facility in which the grantor is a patient, unless the employee serves as a notary public; (d) An attending physician of the gic or other person authorized to administer oaths in regard to any advance directive made under this section: (a) A blood relative of the grantor; (b) A beneficiary of the grantor under descent and di grantor and in the presence of each other, or acknowledged before a notary public or other person authorized to administer oaths. None of the following shall be a witness to or serve as a notary publfect the directive. (2) An advance directive shall be in writing, dated, and signed by the grantor, or at the grantor's direction, and either witnessed by two (2) or more adults in the presence of thepted medical practice and not specifically prohibited by any other statute. If any other specific directions are held by a court of appropriate jurisdiction to be invalid, that invalidity shall not afliving will directive (1) A living will directive made pursuant to KRS 311.623 shall be substantially in the following form, and may include other specific directions which are in accordance with acceart on Kentucky Statutes Chapter 311 Section 623 et. Seq. The following are useful excerpts from the Kentucky Statutes relating to the Kentucky Power of Attorney for Health Care Form. 311.625 Form of Information and Instructions Kentucky Living Will This package contains (1) Information and Instruction for Kentucky Living Will; (2) Kentucky Living Will Form. This Kentucky Living Will is based in p Kentucky