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Nebraska eclarant voluntarily signed this writing in my presence. ______________________________________ (Notary Public) ____________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ OR The D____ The Declarant voluntarily signed this writing in my presence. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: __________igned this _____ day of _________., 20___ __________________________________________ (Declarant's Signature) Print Name: ___________________________________ Address: __________________________________tment, I direct my attending physician, pursuant to the Rights of the Terminally Ill Act, to withhold or withdraw life sustaining treatment that is not necessary for my comfort or to alleviate pain. Sstration of life-sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treamers and Terms of Use found at findlegalforms.com Living Will DECLARATION If I should lapse into a persistent vegetative state or have an incurable and irreversible condition that, without the admini with estate planning matters. 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 Disclaiting point for you and should 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 dealinggal effect or completeness. [_]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 star declarant's medical record. [_] These forms are provided "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 lethe attending physician or other health care provider by the declarant or a witness to the revocation. (2) The attending physician or other health care provider shall make the revocation a part of theration (1) A declarant may revoke a declaration at any time and in any manner without regard to the declarant's mental or physical condition. A revocation shall be effective upon its communication to operative, the attending physician and other health care providers shall act in accordance with its provisions or comply with the transfer requirements of section 20-409. 20-406 - Revocation of declaified a reasonably available member of the declarant's immediate family or guardian, if any, of his or her diagnosis and of the intent to invoke the patient's declaration. When the declaration becomesgetative state, (3) the declarant is determined by the attending physician to be unable to make decisions regarding administration of life-sustaining treatment, and (4) the attending physician has noteclaration shall become operative when (1) it is communicated to the attending physician, (2) the Declarant is determined by the attending physician to be in a terminal condition or in a persistent vethe declaration shall make it a part of the declarant's medical record and, if unwilling to comply with the declaration, shall promptly so advise the declarant. 20-405 - When declaration operative A dg a physician to withhold or withdraw life-sustaining treatment may, but need not, be in the form provided in this subsection. (3) A physician or other health care provider who is furnished a copy of e or health insurance provider for the declarant. The restrictions upon who may witness the signing shall not apply to a notary public. Information & Instructions ­ Page 3 (2) A declaration directinlic. No more than one witness to a declaration shall be an administrator or employee of a health care provider who is caring for or treating the declarant, and no witness shall be an employee of a lifg the withholding or withdrawal of life-sustaining treatment. The declaration must be signed by the declarant or another person at the declarant's direction and witnessed by two adults or a notary pubg physician, result in death within a relatively short time. 20-404 - Declaration relating to use of life-sustaining treatment (1) An adult of sound mind may execute at any time a declaration governinof the United States; and (11) Terminal condition shall mean an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of the attendinstent vegetative state; (10) State shall mean a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction ractice medicine in this state; (9) Qualified patient shall mean an adult who has executed a declaration and who has been determined by the attending physician to be in a terminal condition or a persiership, limited liability company, association, joint venture, government, governmental subdivision or agency, or other legal or commercial entity; (8) Physician shall mean an individual licensed to p consciousness and capacity for cognitive interaction with the environment and no reasonable hope of improvement; (7) Person shall mean an individual, corporation, business trust, estate, trust, partnl mean a medical condition that, to a reasonable degree of medical certainty as determined in accordance with currently accepted medical standards, is characterized by a total and irreversible loss ofthat, when administered to a qualified patient, will serve only to prolong the process of dying or maintain the qualified patient in a persistent vegetative state; (6) Persistent vegetative state shalrized by the law of this state to administer health care in the ordinary course of business or practice of a profession; (5) Life-sustaining treatment shall mean any medical procedure or intervention ation shall mean a writing executed in accordance with the requirements of subsection (1) of section 20-404; (4) Health care provider shall mean a person who is licensed, certified, or otherwise autho who is or has been married; (2) Attending physician shall mean the physician who has primary responsibility for the treatment and care of the patient; Information & Instructions ­ Page 2 (3) Declarally Ill Act. 20-403 - Definitions For purposes of the Rights of the Terminally Ill Act, unless the context otherwise requires: (1) Adult shall mean any person who is nineteen years of age or older or. Remedy in law and equity may be granted by a court of competent jurisdiction. (2) It is the public policy of this state that no existing right be terminated or restricted by the Rights of the Terminon described in the act, for people to exercise their rights. Unjustifiable violation of a patient's direction shall be a civil cause of action maintainable by the patient or the patient's next of kin, protecting dependent third parties, and maintaining the integrity of the medical profession. The Legislature adopts the Rights of the Terminally Ill Act to provide one means, by use of the declaratiliberty interest for people to direct their medical treatment. The exercise of such right and liberty interest is subject to certain state interests in preserving life, preventing homicide and suicide01 to 20-416 shall be known and may be cited as the Rights of the Terminally Ill Act. 20-402 - Statement of policy (1) The Legislature recognizes the common-law right and a constitutionally protected r 20 Section 20-401 et. Seq. of the Nebraska Statutes. For your convenience, we have included useful excerpts from the Nebraska Statutes relating to Living Wills. 20-401 - Act, how cited Sections 20-4Information and Instructions Nebraska Living Will This package contains (1) Information and Instruction for Nebraska Living Will; (2) Nebraska Living Will. This Nebraska Living Will is based on Chapte Nebraska