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Missouri ation. __________________________________________ (Declarant's Signature Date ______________________________________ ______________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ REVOCATION PROVISION I hereby revoke the above declarcument in my presence. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ ______________________ City, County and State of residence ._____________________________________________ The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this do Signed this _____________ day of ______________, _____________ . __________________________________________ (Declarant's Signature) Name: _____________________________________________________________re not necessary to my comfort or to alleviate pain. 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.minal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and ay physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is ternd at findlegalforms.com Living Will DECLARATION I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to mters. Any possible tax consequences 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 fouould not be used or signed without 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 mat2 [_]These forms are not intended 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 shs" 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. Information & Instructions ­ Page ffect other directions of the declaration which can be given effect without the invalid declaration, and to this end the directions in the declaration are severable. [_] These forms are provided "as ibe necessary to use this sample form. In addition, the declaration may include other specific directions. Should any of the other specific directions be held to be invalid, such invalidity shall not at's medical records as maintained by his attending physician and the medical records of any health facility of which he is a patient. 3. The declaration may be in the following form, but it shall not onsibility of the declarant to provide for notification to his attending physician of the existence of the declaration. Upon the request of the patient, the declaration shall be placed in the declaran witnesses at least eighteen years of age neither of whom shall be the person who signed the declaration on behalf of and at the direction of the person making the declaration. 2. It shall be the respion, or by another person in the declarant's presence and by the declarant's expressed direction; (3) Dated; and (4) If not wholly in the declarant's handwriting, signed in the presence of two or moreecting the withholding or withdrawal of death-prolonging procedures. The declaration made pursuant to sections 459.010 to 459.055 shall be: (1) In writing; (2) Signed by the person making the declaratort ) Section 459.015 Declaration, who may execute requirements of declaration--form --witnesses required, when-notice to physician--filed--where. 1. Any competent person may execute a declaration dirr 459 Section 459.015 of the Missouri Revised Statutes. For your convenience, we have included useful excerpts from the Missouri Statutes relating to Living Wills. Chapter 459 (Declarations, Life SuppInformation and Instructions Missouri Living Will This package contains (1) Information and Instruction for Missouri Living Will; (2) Missouri Living Will. This Missouri Living Will is based on Chapte Missouri