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Mississippi _________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Social Security Number:__________________________ itness Signature) Print Name: ___________________________________ Address: ______________________________________ Social Security Number:__________________________ ____________________________________on of law, and (d) Am not a physician attending the maker of the revocation or a person employed by a physician attending the maker of this revocation. _____________________________________________ (Wy blood or marriage, (b) Do not have any claim on the estate of the maker of this revocation, (c) Am not entitled to any portion of the estate of the maker of this revocation by any will or by operati and believe the maker of this revocation to be of sound mind. (2) To the best of my knowledge, at the time of the execution of this revocation, I: (a) Am not related to the maker of this revocation b__ (date declaration made) regarding the manner in which I die. SIGNED ____________________________ I hereby witness this revocation and attest that: (1) I personally know the maker of this revocatione), of _____________________________________________________________ (address), _____________________________ (Social Security Number), being of sound mind, revoke the declaration made on ____________: ___________________________________ Social Security Number: ______________________ Revocation Of Declaration On ______________ (date), I, _____________________________________________ (person's nam ___________________________________ Social Security Number: ______________________ ___________________________________________ (Witness Signature) Print Name: ________________________________ Addresstending the Declarant or a person employed by a physician attending the Declarant. ___________________________________________ (Witness Signature) Print Name: ________________________________ Address:od or marriage, (b) Do not have any claim on the estate of the Declarant, (c) Am not entitled to any portion of the Declarant's estate by any will or by operation of law, and (d) Am not a physician atnally know the Declarant and believe the Declarant to be of sound mind. (2) To the best of my knowledge, at the time of the execution of this declaration, I: (a) Am not related to the Declarant by bloy family and my physician as the final expression of my desires concerning the manner in which I die. SIGNED ____________________________ I hereby witness this declaration and attest that: (1) I persoas pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy. I further declare that this declaration shall be honored by mmeaningful to me and but for the use of life-sustaining mechanisms my death would be imminent, I desire that the mechanisms be withdrawn so that I may die naturally. However, if I have been diagnosed evere distress or unconsciousness, and my physician, with the concurrence of two (2) other physicians, believes that there is no expectation of my regaining consciousness or a state of health that is _ (Social Security Number). I, ________________________________________________________ being of sound mind, declare that if at any time I should suffer a terminal physical condition which causes me sng Will DECLARATION made on ______________ (date) by ________________________________ (person's name) of ________________________________________________________ (address), ___________________________ences arising 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 Livihout consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequnded and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed wited "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intecious or unable to make his wishes known, if said Declarant revokes his declaration. The physician's determination of Declarant's response in such situations shall be final. [_] These forms are provid executed a declaration in conformance with sections 41-41-101 et seq. may ask the Declarant, prior to procedures which might reasonably be expected to cause the Declarant to become permanently unconsise, of the Declarant's wish to revoke the authorization is effective as a revocation of the authorization. (4) An attending physician having actual knowledge or reason to believe that his patient hasarant wishes to revoke the authorization of life-sustaining mechanisms but is unable physically to execute a revocation as provided in this section, a clear expression by the Declarant, oral or otherwe revocation which shall be in substantially the following form: (Form included below) (2) The revocation shall be filed with the bureau of vital statistics of the state board of health. (3) If a Declion; form. (1) A declaration executed as provided in section 41-41-107 may be revoked by a revocation signed by the Declarant and at least two (2) persons who witnessed the Declarant's execution of the in substantially the following form: (Form included below) (2) The declaration shall be filed with the bureau of vital statistics of the state board of health. SEC. 41-41-109. Revocation of declarat1) The authorization for withdrawal of life-sustaining mechanisms must be a declaration signed by at least two (2) persons who witnessed the execution of the declaration by the Declarant which shall bon have a claim against any portion of the estate of the Declarant or maker of the revocation upon the death of the Declarant or maker of the revocation. SEC. 41-41-107. Declaration of intent; form. (f a health facility in which the Declarant or maker of the revocation is a patient; or Information & Instructions ­ Page 2 (d) Persons who at the time of the execution of the declaration or revocatiDeclarant or maker of the revocation or by operation of law at the time of the execution of the declaration or revocation; or (c) The attending physician or an employee of the attending physician or oe Declarant or maker of the revocation by blood or marriage; or (b) Entitled to any portion of the estate of the Declarant or maker of the revocation upon his decease under any will or codicil of the nly if signed by the Declarant or maker of the revocation in the presence of at least two (2) attesting witnesses who, at the time the declaration or revocation is executed, are not: (a) Related to thcation; witnesses. A declaration made pursuant to section 41-41-107 and a revocation made pursuant to section 4141-109, except for the type of revocation provided by section 41-41-109 (3), are valid opetency. Any person of the age of eighteen (18) years or older who is mentally competent may authorize withdrawal of life-sustaining mechanisms. SEC. 41-41-111. Signature of Declarant or maker of revoms" shall mean the cessation of use of extraordinary techniques and applications, including mechanical devices, which prolong life through artificial means. SEC. 41-41-105. Age requirement; mental comerein unless the context otherwise requires: (a) "Physician" shall mean a person licensed to practice medicine in any state in the United States of America. (b) "Withdrawal of life-sustaining mechanisuded useful excerpts from the Mississippi Statutes relating to Living Wills. SEC. 41-41-103. Definitions. For purposes of Secs. 41-41-101 et seq., the following words shall have the meaning ascribed haration (Living Will Revocation). The Mississippi Living Will and Revocation are based on Title 41 Chapter 041 Section 41-41103 et. Seq. of the Mississippi Statutes. For your convenience, we have inclInformation and Instructions Mississippi Living Will & Revocation This package contains (1) Information and Instruction for Mississippi Living Will; (2) Mississippi Living Will; (3) Revocation of Decl Mississippi