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North Carolina or Notary Public (circle one as appropriate) for the County of ____________________________ 2 ineness and due execution of the declaration. This the ____ day of ___________, _________.(month and year) __________________________________________________ Clerk (Assistant Clerk) of Superior Court t or an employee of a nursing home or any group-care home in which the declarant resided, and (iv) they did not have a claim against the declarant. I further certify that I am satisfied as to the genus it provides at that time, and (iii) they were not a physician attending the declarant or an employee of an attending physician or an employee of a health facility in which the declarant was a patienthey would be entitled to any portion of the estate of the declarant upon the declarant's death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act ae time they witnessed the declaration (i) they were not related within the third degree to the declarant or to the declarant's spouse, and (ii) they did not know or have a reasonable expectation that s, appeared before me and swore that they witnessed ____________________________________________, declarant, sign the attached declaration, believing him to be of sound mind; and also swore that at thact and deed for the purposes expressed in it. I further certify that __________________________________________________________ and __________________________________________________________ witnesseand swore to me and to the witnesses in my presence that this instrument is his Declaration Of A Desire For A Natural Death, and that he had willingly and voluntarily made and executed it as his free rior Court or Notary Public (circle one as appropriate) for __________________ County hereby certify that __________________________________________________________, the declarant, appeared before me clerk or the assistant clerk, or a notary public may, upon proper proof, certify the declaration as follows: Certificate I, _________________________________________, Clerk (Assistant Clerk) of Supe______________ (Witness Signature) Print Name: ___________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ The 1 patient or an employee of a nursing home or any group-care home where the declarant resides. I further state that I do not now have any claim against the declarant. _______________________________te without a will. I also state that I am not the declarant's attending physician or an employee of the declarant's attending physician, or an employee of a health facility in which the declarant is a I would be entitled to any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir under the Intestate Succession Act if the declarant died on this da__________, being of sound mind signed the above declaration in my presence and that I am not related to the declarant by blood or marriage and that I do not know or have a reasonable expectation thatay of _______________, ________________ (month and year) __________________________________________ (Declarant's Signature) I hereby state that the declarant, _________________________________________n addition to withholding or discontinuing extraordinary means if such means are necessary, physician may withhold or discontinue either artificial nutrition or hydration, or both. This the ________ dth. _________ If my physician determines that I am in a persistent vegetative state, I authorize the following: _________ My physician may withhold or discontinue extraordinary means only. _________ Ins only. _________ In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or boany of the following, as desired): _________ If my condition is determined to be terminal and incurable, I authorize the following: _________ My physician may withhold or discontinue extraordinary meaunderstand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration, in accordance with my specifications set forth below: (Initial y extraordinary means or by artificial nutrition or hydration if my condition is determined to be terminal and incurable or if I am diagnosed as being in a persistent vegetative state. I am aware and Living Will Declaration Of A Desire For A Natural Death I, _________________________________________________________, being of sound mind, desire that, as specified below, my life not be prolonged bonsequences 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.comed 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 matters. Any possible tax ct 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 should not be used or signprovided "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 noicle 3 of Chapter 32A of the General Statutes; provided, however, that the resulting form shall be signed, witnessed, and proved in accordance with the provisions of this section. [_] These forms are prior to July 1, 1979, shall continue to be valid. (j) The form provided by this section may be combined with or incorporated into a health care power of attorney form meeting the requirements of Artgainst whom criminal or civil liability is asserted because of conduct in compliance with this section may interpose this section as a defense. (i) Any certificate in the form provided by this sectionh in accordance with this section shall not be considered the cause of death for any civil or criminal purposes nor shall it be considered unprofessional conduct. Any person, institution or facility antract or for receiving any medical treatment. (h) The withholding or discontinuance of extraordinary means and/or the withholding or discontinuance of either artificial nutrition or hydration, or botor any purpose. Information & Instructions ­ Page 3 (g) No person shall be required to sign a declaration in accordance with subsection (c) as a condition for becoming insured under any insurance coysician by the declarant or by an individual acting on behalf of the declarant. (f) The execution and consummation of declarations made in accordance with subsection (c) shall not constitute suicide fy manner by which he is able to communicate his intent to revoke, without regard to his mental or physical condition. Such revocation shall become effective only upon communication to the attending phf the handwriting of the two witnesses whose testimony is unavailable, and b. Upon compliance with paragraph c of subdivision (2) above. (e)The above declaration may be revoked by the declarant, in aness and due execution of the declaration. (3) If the testimony of none of the witnesses is available, such declaration may be proved by the clerk or assistant clerk, or a notary public a. Upon proof oting of the declarant, unless he signed by his mark; or upon proof of such other circumstances as will satisfy the clerk or assistant clerk of the superior court, or a notary public as to the genuinen is available, then a. Upon the testimony of such witness, and b. Upon proof of the handwriting of the witness who is dead or whose testimony is otherwise unavailable, and c. Upon proof of the handwri . . declaration may be proved by the clerk or the assistant clerk, or a notary public in the following manner: (1) Upon the testimony of the two witnesses; or (2) If the testimony of only one witnessf superior court, or a notary public who certifies substantially as set out in subsection (d) below. (d) The following form is specifically determined to meet the requirements above: (See Below) The .the declarant resides, and (iv) do not have a claim against any portion of the estate of the declarant at the time of the declaration; and (4) Which has been proved before a clerk or assistant clerk otending physician, or an employee of the attending physician, or an employee of a health facility in which the declarant is a patient, or an employee of a nursing home or any group-care home in which y portion of the estate of the declarant upon his death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it then provides, (iii) are not the atd and who state that they (i) are not related within the third degree to the declarant or to the declarant's spouse, (ii) do not know or have a reasonable expectation that they would be entitled to anr discontinue the extraordinary means or artificial nutrition or hydration; and (3) Which has been signed by the declarant in the presence of two witnesses who believe the declarant to be of sound minal and incurable, or if the declarant is diagnosed as being in a persistent vegetative state; and (2) Which states that the declarant is aware that the declaration authorizes a physician to withhold o desire of the declarant that extraordinary means or artificial nutrition or hydration not be used to prolong his life if his condition is determined to be Information & Instructions ­ Page 2 termin of that declaration obtained from the Advance Health Care Directive Registry maintained by the Secretary of State pursuant to Article 21 of Chapter 130A of the General Statutes; (1) Which expresses awithheld or discontinued upon the direction and under the supervision of the attending physician. (c) The attending physician may rely upon a signed, witnessed, dated and proved declaration, or a copyondition as set out above in subdivision (b)(1) by a physician other than the attending physician; then extraordinary means or artificial nutrition or hydration, as specified by the declarant, may be nt condition is a. Terminal and incurable; or b. Repealed by Session Laws 1993, c. 553, s. 28; c. Diagnosed as a persistent vegetative state; and (2) There is confirmation of the declarant's present ceans or by artificial nutrition or hydration, and the declaration has not been revoked in accordance with subsection (e); and (1) It is determined by the attending physician that the declarant's preseion or hydration, will succumb to death within a short period of time. (b) If a person has declared, in accordance with subsection (c) below, a desire that his life not be prolonged by extraordinary mcondition whereby in the judgment of the attending physician the patient suffers from a sustained complete loss of self-aware cognition and, without the use of extraordinary means or artificial nutritvital function; (3) "Physician" means any person licensed to practice medicine under Article 1 of Chapter 90 of the laws of the State of North Carolina; (4) "Persistent vegetative state" is a medical ined as any medical procedure or intervention which in the judgment of the attending physician would serve only to postpone artificially the moment of death by sustaining, restoring, or supplanting a 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 accordance with subsection (c); (2) "Extraordinary means" is def Will is based on Chapter 90 Section 90-321 et. Seq. of the North Carolina Statutes. For your convenience, we have included useful excerpts from the North Carolina Statutes relating to Living Wills. §Information and Instructions North Carolina Living Will This package contains (1) Information and Instruction for North Carolina Living Will; (2) North Carolina Living Will. This North Carolina Living North Carolina