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North Carolina ar) __________________________________________________ Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for the County of ____________________________ 2 did not have a claim against the declarant. I further certify that I am satisfied as to the genuineness and due execution of the declaration. This the ____ day of ___________, _________.(month and yeof an attending physician or an employee of a health facility in which the declarant was a patient or an employee of a nursing home or any group-care home in which the declarant resided, and (iv) theyny will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the declarant or an employee t or to the declarant's spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon the declarant's death under arant, sign the attached declaration, believing him to be of sound mind; and also swore that at the time they witnessed the declaration (i) they were not related within the third degree to the declaran_________________________ and __________________________________________________________ witnesses, appeared before me and swore that they witnessed ____________________________________________, decla For A Natural Death, and that he had willingly and voluntarily made and executed it as his free act and deed for the purposes expressed in it. I further certify that _________________________________at __________________________________________________________, the declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his Declaration Of A Desirellows: Certificate I, _________________________________________, Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for __________________ County hereby certify th________________________ (Witness Signature) Print Name: ___________________________________ The clerk or the assistant clerk, or a notary public may, upon proper proof, certify the declaration as fo state that I do not now have any claim against the declarant. _____________________________________________ (Witness Signature) Print Name: ___________________________________ _____________________clarant's attending physician, or an employee of a health facility in which the declarant is a 1 patient or an employee of a nursing home or any group-care home where the declarant resides. I furtherhe declarant or as an heir under the Intestate Succession Act if the declarant died on this date without a will. I also state that I am not the declarant's attending physician or an employee of the dehe declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the declarant under any existing will or codicil of tant's Signature) I hereby state that the declarant, ___________________________________________________, being of sound mind signed the above declaration in my presence and that I am not related to thhold or discontinue either artificial nutrition or hydration, or both. This the ________ day of _______________, ________________ (month and year) __________________________________________ (Declarg: _________ My physician may withhold or discontinue extraordinary means only. _________ In addition to withholding or discontinuing extraordinary means if such means are necessary, physician may wit, my physician may withhold or discontinue either artificial nutrition or hydration, or both. _________ If my physician determines that I am in a persistent vegetative state, I authorize the followinhorize the following: _________ My physician may withhold or discontinue extraordinary means only. _________ In addition to withholding or discontinuing extraordinary means if such means are necessaryal nutrition or hydration, in accordance with my specifications set forth below: (Initial any of the following, as desired): _________ If my condition is determined to be terminal and incurable, I aut incurable or if I am diagnosed as being in a persistent vegetative state. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artifici________, being of sound mind, desire that, as specified below, my life not be prolonged by extraordinary means or by artificial nutrition or hydration if my condition is determined to be terminal and of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will Declaration Of A Desire For A Natural Death I, _________________________________________________torney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use state. These forms should only be a starting 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 ator 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 to time and from state tonessed, and proved in accordance with the provisions of this section. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability f or incorporated into a health care power of attorney form meeting the requirements of Article 3 of Chapter 32A of the General Statutes; provided, however, that the resulting form shall be signed, witerpose this section as a defense. (i) Any certificate in the form provided by this section prior to July 1, 1979, shall continue to be valid. (j) The form provided by this section may be combined withs nor shall it be considered unprofessional conduct. Any person, institution or facility against whom criminal or civil liability is asserted because of conduct in compliance with this section may intd/or the withholding or discontinuance of either artificial nutrition or hydration, or both in accordance with this section shall not be considered the cause of death for any civil or criminal purpose accordance with subsection (c) as a condition for becoming insured under any insurance contract or for receiving any medical treatment. (h) The withholding or discontinuance of extraordinary means anarations made in accordance with subsection (c) shall not constitute suicide for any purpose. Living Will Information & Instructions ­ Page 3 (g) No person shall be required to sign a declaration in revocation shall become effective only upon communication to the attending physician by the declarant or by an individual acting on behalf of the declarant. (f) The execution and consummation of declion (2) above. (e)The above declaration may be revoked by the declarant, in any manner by which he is able to communicate his intent to revoke, without regard to his mental or physical condition. Such be proved by the clerk or assistant clerk, or a notary public a. Upon proof of the handwriting of the two witnesses whose testimony is unavailable, and b. Upon compliance with paragraph c of subdivisr assistant clerk of the superior court, or a notary public as to the genuineness and due execution of the declaration. (3) If the testimony of none of the witnesses is available, such declaration may or whose testimony is otherwise unavailable, and c. Upon proof of the handwriting of the declarant, unless he signed by his mark; or upon proof of such other circumstances as will satisfy the clerk ohe testimony of the two witnesses; or (2) If the testimony of only one witness is available, then a. Upon the testimony of such witness, and b. Upon proof of the handwriting of the witness who is dead is specifically determined to meet the requirements above: (See Below) The . . . declaration may be proved by the clerk or the assistant cle rk, or a notary public in the following manner: (1) Upon teclaration; and (4) Which has been proved before a clerk or assistant clerk of superior court, or a notary public who certifies substantially as set out in subsection (d) below. (d) The following form a patient, or an employee of a nursing home or any group-care home in which the declarant resides, and (iv) do not have a claim against any portion of the estate of the declarant at the time of the d under the Intestate Succession Act as it then provides, (iii) are not the attending physician, or an employee of the attending physician, or an employee of a health facility in which the declarant is not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon his death under any will of the declarant or codicil the reto then existing orn the presence of two witnesses who believe the declarant to be of sound mind and who state that they (i) are not related within the third degree to the declarant or to the declarant's spouse, (ii) dodeclarant is aware that the declaration authorizes a physician to withhold or discontinue the extraordinary means or artificial nutrition or hydration; and (3) Which has been signed by the declarant iis determined to be Living Will Information & Instructions ­ Page 2 terminal and incurable, or if the declarant is diagnosed as being in a persistent vegetative state; and (2) Which states that the 1 of Chapter 130A of the General Statutes; (1) Which expresses a desire of the declarant that extraordinary means or artificial nutrition or hydration not be used to prolong his life if his condition pon a signed, witnessed, dated and proved declaration, or a copy of that declaration obtained from the Advance Health Care Directive Registry maintained by the Secretary of State pursuant to Article 2l nutrition or hydration, as specified by the declarant, may be withheld or discontinued upon the direction and under the supervision of the attending physician. (c) The attending physician may rely utate; and (2) There is confirmation of the declarant's present condition as set out above in subdivision (b)(1) by a physician other than the attending physician; then extraordinary means or artificiadetermined by the attending physician that the declarant's present condition is a. Terminal and incurable; or b. Repealed by Session Laws 1993, c. 553, s. 28; c. Diagnosed as a persistent vegetative selow, a desire that his life not be prolonged by extraordinary means or by artificial nutrition or hydration, and the declaration has not been revoked in accordance with subsection (e); and (1) It is and, without the use of extraordinary means or artificial nutrition or hydration, will succumb to death within a short period of time. (b) If a person has declared, in accordance with subsection (c) b North Carolina; (4) "Persistent vegetative state" is a medical condition whereby in the judgment of the attending physician the patient suffers from a sustained complete loss of self-aware cognition the moment of death by sustaining, restoring, or supplanting a vital function; (3) "Physician" means any person licensed to practice medicine under Article 1 of Chapter 90 of the laws of the State ofaccordance with subsection (c); (2) "Extraordinary means" is defined as any medical procedure or intervention which in the judgment of the attending physician would serve only to postpone artificiallyts from the North Carolina Statutes relating to Living Wills. § 90-321. Right to a natural death. (a) As used in this Article the term: (1) "Declarant" means a person who has signed a declaration in ill; (2) North Carolina Living Will. This North Carolina Living Will is based on Chapter 90 Section 90-321 et. Seq. of the North Carolina Statutes. For your convenience, we have included useful excerper of attorney, and to your physician and family members.) 7 Information and Instructions North Carolina Living Will This package contains (1) Information and Instruction for North Carolina Living W________________________________ Notary Public My Commission Expires: _______________________________ (A copy of this form should be given to your health care agent and any alternate named in this pow(iv) they did not have a claim against him/her. I further certify that I am satisfied as to the genuineness and due execution of the instrument. This the __________ day of _______________, 20____. ___r, nor an employee of an attending physician, nor an employee of a health facility in which he/she was a patient, nor an employee of a nursing home or any group-care home in which he/she resided, and is/her estate upon his/her death under any will or codicil thereto then existing or under the Intestate Succession Act as it provided at that time, and (iii) they were not a physician attending him/hethe signing (i) they were not related within the third degree to him/her or his/her spouse, and (ii) they did not know nor have a reasonable expectation that they would be entitled to any portion of hefore me and swore that they witnessed _________________________ sign the attached health care power of attorney, believing him/her to be of sound mind; and also swore that at the time they witnessed luntarily made and executed it as his/her free act and deed for the purposes expressed in it. I further certify that ____________________________ and ___________________________, witnesses, appeared bhat _______________________________ appeared before me and swore to me and to the witnesses in my presence that this 6 instrument is a health care power of attorney, and that he/she willingly and vo_____________ STATE OF North Carolina COUNTY OF _______________________ CERTIFICATE I, _________________________________, a Notary Public for _________________ County, North Carolina, hereby certify tI further state that I do not nave any claim against the principal. Witness: ______________________________________ Date: __________________ Witness: ______________________________________ Date: _____ the principal's attending physician, nor an employee of the health facility in which the principal is a patient, nor an employee of a nursing home or any group care home where the principal resides. of the principal or as an heir under the Intestate Succession Act, if the principal died on this date without a will. I also state that I am not the principal's attending physician, nor an employee of attorney in my presence, and that I am not related to the principal by blood or marriage, and I would not be entitled to any portion of the estate of the principal under any existing will or codicil ________ Date _______________ (SEAL) 9. Signatures of Witnesses. I hereby state that the Principal, ____________________________________, being of sound mind, signed the foregoing health care power oflert and competent, fully informed as to the contents of this document, and understand the full import of this grant of powers to my health care agent. Signature of Principal__________________________ty is asserted because of conduct authorized by this health care power of attorney may interpose this document as a defense. 8. Signature of principal. By signing here, I indicate that I am mentally afor any civil or criminal purposes, nor shall it be considered unprofessional conduct or as lack of professional competence. Any person, institution, or facility against whom criminal or civil liabilinstitution, or facility acting in good faith in reliance on the authority of my health care agent pursuant to this health care power of attorney shall be considered suicide, nor the cause of my death of the acts or omissions of my health care agent pursuant to this document, except for willful misconduct or gross negligence. D. No act or omission of my health care agent, or of any other person, is are hereby released and forever discharged by me, my estate, my heirs, successors, and assigns and personal representatives from all liability and from all claims or demands of all kinds arising outto my health care, my health care agent shall not have any authority over my property or financial affairs. 5 C. My health care agent and my health care agent's estate, heirs, successors, and assign incur reasonable costs on my behalf incident to the exercise of these powers; provided, however, that except as shall be necessary in order to exercise the powers described in this document relating , deliver, and acknowledge any contract or other document that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of the powers described in this document and toand binding upon my family, relatives, friends, and others. 7. Miscellaneous provisions. A. I revoke any prior health care power of attorney. B. My health care agent shall be entitled to sign, executere to the benefit of and bind me, my estate, my heirs, successors, assigns, and personal representatives. The authority of my health care agent pursuant to this power of attorney shall be superior to ith by my health care agent pursuant to this power of attorney are done with my consent and sha ll have the same validity and effect as if I were present and exercised the powers myself, and shall inu document may be accepted by persons as fully authorized by me and with the same force and effect as if I were personally present, competent, and acting on my own behalf. All acts performed in good fa agent. B. The powers conferred on my health care agent by this document may be exercised by my health care agent alone, and my health care agent's signature or act under the authority granted in thisthe authority of or any representations by my health care agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions by my health care person, to serve without bond or security. The guardian shall act consistently with G.S. 35A-1201(a)(5). 6. Reliance of third parties on health care agent. A. No person who relies in good faith upon _________________ 5. Guardianship provision. If it becomes necessary for a court to appoint a guardian of my person, I nominate my health care agent acting under this document to be the guardian of my_______________________________________________________________________ ________________________________________________________________________ _______________________________________________________advance instruction, you should indicate here whether you have executed an advance instruction for mental health treatment.): ________________________________________________________________________ _ing or capacity to make or communicate mental health treatment decisions. Because your health care agent's decisions about decisions must be consistent with any 4 statements you have expressed in an accordance with Part 2 of Article 3 of Chapter 122C of the General Statutes, which you may use to state your instructions regarding mental health treatment in the event you lack sufficient understand_____________________________________________________ C. (Notice: This health care power of attorney may incorporate or be combined with an advance instruction for mental health treatment, executed inent that are unacceptable to you): ________________________________________________________________________ ________________________________________________________________________ ___________________ electroconvulsive treatment (ECT), instructions regarding your admission to and retention in a health care facility for mental health treatment, or instructions to refuse any specific types of treatmm appropriate such as: limiting the grant of authority to make only mental health treatment decisions, your own instructions regarding the administration or withholding of psychotropic medications and make mental health decisions on my behalf, the authority of my health care agent is subject to the following special provisions and limitations. (Here you may include any specific limitations you dee____________________ ________________________________________________________________________ ________________________________________________________________________ B. In exercising the authority toith your religious beliefs, or unacceptable to you for any other reason.): ________________________________________________________________________ ____________________________________________________ou deem appropriate such as: your own definition of when life-sustaining treatment should be withheld or discontinued, or instructions to refuse any specific types of treatment that are inconsistent wority to make health care decisions on my behalf, the authority of my health care agent is subject to the fo llowing special provisions and limitations (Here you may include any specific limitations yny decisions you could make to obtain or terminate any type of health care. If you wish to limit the scope of your health care agent's powers, you may do so in this section.) A. In exercising the authility to medical providers. 4. Special provisions and limitations. (Notice: The above grant of power is intended to be as broad as possible so that your health care agent will have authority to make a, to authorize an autopsy, and to direct the disposition of my remains. 3 I. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liab COMA, SUFFER SEVERE DEMENTIA, OR AM IN A PERSISTENT VEGETATIVE STATE. H. To exercise any right I may have to make a disposition of any part or all of my body for medical purposes, to donate my organs-sustaining procedures do not include care necessary to provide comfort or alleviate pain. I DESIRE THAT MY LIFE NOT BE PROLONGED BY LIFE-SUSTAINING PROCEDURES IF I AM TERMINALLY ILL, PERMANENTLY IN A and may include mechanical ventilation, dialysis, antibiotics, artificial nutrition and hydration, and other forms of medical treatment which sustain, restore or supplant vital bodily functions. Lifemanently in a coma, suffer severe dementia, or am in a persistent vegetative state. Life-sustaining procedures are those forms of medical care that only serve to artificially prolong the dying processludes the power to consent to measures for relief of pain. G. To authorize the withholding or withdrawal of life-sustaining procedures when and if my physician determines that I am terminally ill, perhesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed physician, dentist, or podiatrist. This authorization specifically incs for mental health treatment and electroconvulsive treatment (ECT) commonly referred to as "shock treatment". F. To give consent for, to withdraw consent for, or to withhold consent for, X ray, anesther institution. D. To consent to and authorize my admission to and retention in a facility for the care or treatment of mental illness. E. To consent to and authorize the administration of medicationhe disclosure of this information. B. To employ or discharge my health care providers. C. To consent to and authorize my admission to and discharge from a hospital, nursing or convalescent home, or otllowing: A. To request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and to consent to tereby grant to my health care agent named above full power and authority to make health care decisions, including mental health treatment decisions, on my behalf, including, but not limited to, the fo_____________________________________ 2 ________________________________________________________________________ 3. General statement of authority granted. Except as indicated in section 4 below, I hcomes effective.): ________________________________________________________________________ ________________________________________________________________________ ___________________________________ligible psychologist. You may also name two or more physicians or eligible psychologists, if desired, both of whom must make this determination before the authority granted to the health care agent bee made by the following physician or eligible psychologist. (You may include here a designation of your choice, including your attending physician or eligible psychologist, or any other physician or e in effect during my incapacity, until my death. This determination shall be made by the following physician or physicians. For decisions related to mental health treatment, this determination shall bective when and if the physician or physicians designated below determine that I lack sufficient understanding or capacity to make or communicate decisions relating to my health care and will continueny manner by which you are able to communicate your intent to revoke to your health care agent and your attending physician.) Absent revocation, the authority granted in this document shall become effested with the same power and duties as if originally named as my health care agent. 2. Effectiveness of appointment. (Notice: This health care power of attorney may be revoked by you at any time in a___________________________________________________________ Home Telephone Number ____________________ Work Telephone Number ____________________ Each successor health care agent designated shall be v________________________ Home Telephone Number _____________________ Work Telephone Number _____________________ B. Name: _______________________________________________________________ Home Address: and successively, in the order named), to serve in that capacity: (Optional) A. Name: _______________________________________________________________ Home Address: ___________________________________ized in this document. 1 If the person named as my health care agent is not reasonably available or is unable or unwilling to act as my agent, then I appoint the following persons (each to act alone______ as my health care attorney- in-fact (herein referred to as my "health care agent") to act for me and in my name (in any way I could act in person) to make health care decisions for me as author_______________________________________________ Home Address: ______________________________________________________________ Home Telephone Number __________________ Work Telephone Number ____________health care that meets the statutory requirements.) 1. Designation of health care agent. I, __________________________________________, being of sound mind, hereby appoint Name: ______________________se of this form is an optional and nonexclusive method for creating a health care power of attorney and North Carolina law does not bar the use of any other or different form of power of attorney for and other health care decisions with your health care agent. Use of this form in the creation of a health care power of attorney is lawful and is authorized pursuant to North Carolina law. However, ud act if you were making the decision. Because the powers granted by this document are broad and sweeping, you should discuss your wishes concerning lifesustaining procedures, mental health treatment,care to act in your best interests and in accordance with this document. For mental health treatment decisions, your health care agent will act according to how the health care agent believes you woul are unable to give informed consent. This form does not impose a duty on your health care agent to exercise granted powers, but when a power is exercised, your health care agent will have to use due nt or stopping treatment necessary to keep you alive, admit you to a facility, and administer certain treatments and medications. This power exists only as to those health care decisions for which your you. Except to the extent that you express specific limitations or restrictions on the authority of your health care agent, this power includes the power to consent to your doctor not giving treatmeney Statutory Form, G.S. 32A-25 (Notice: This document gives the person you designate your health care agent broad powers to make health care decisions, including mental health treatment decisions, foould 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 North Carolina Health Care Power of Attormake sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document shal 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 without consulting an attorney first to 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 intended and are not a substitute for legwn as an Advance Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express North Carolina Advance Health Care Directive This package contains both a North Carolina Power of Attorney for Health Care and a North Carolina Living Will. Together these forms are also sometimes kno North Carolina