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South Dakota 3 d signed the foregoing instrument in my presence. Dated this _____________ day of _____________, __________. ______________________________ (Notary Public) My commission expires: __________________. ________ day of ________ 20___, the declarant, ________________________, and witnesses ____________________________, and _________________________ personally appeared before the undersigned officer an______________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ On this the __e declarant voluntarily signed this document in my presence. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ________________________________________________________ Address: __________________________________________________________________ ______________________________________ Zip Code: ___________________________ 2 Th_________________________________________________________________________ Date: __________________ __________________________________________ (Declarant's Signature) Name: ______________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ___ provisions, or if you want to express some of your other thoughts, you can do so here). ____________________________________________________________________________ __________________________________staining treatment" that may be withheld or withdrawn. (If you do not agree with any of the printed directives and want to write your own, or if you want to write directives in addition to the printed only one): _________ I intend to include this treatment among the "life-sustaining treatment" that may be withheld or withdrawn. _________ I do not intend to include this treatment among the "life-su: "I intend to include this treatment, among the 'life-sustaining treatment' that may be withheld or withdrawn.") With respect to artificial nutrition and hydration, I wish to make clear that (initialprovided by means of a nasogastric tube or tubes inserted into the stomach, intestines, or veins. If you do not wish to receive this form of treatment, you must initial the statement below which reads. Preserve my life as long as possible, but do not provide treatment that is not in accordance with accepted medical standards as then in effect. (Artificial nutrition and hydration is food and water to me, terminate it. If and so long as you believe that treatment has a reasonable possibility of restoring consciousness to me, then provide life-sustaining treatment. 1 _________ MAXIMUM TREATMENTieve that I am permanently unconscious and are satisfied that this condition is irreversible, then do not provide me with life-sustaining treatment, and if life-sustaining treatment is being provided only if and for so long as you believe treatment offers a reasonable possibility of restoring to me the ability to think and act for myself. _________ TREAT UNLESS PERMANENTLY UNCONSCIOUS. If you belUSTAINING TREATMENT. I direct that no life-sustaining treatment be provided. If life-sustaining treatment is begun, terminate it. _________ TREATMENT FOR RESTORATION. Provide life-sustaining treatmentonly one of the following optional directives if you agree. If you do not agree with any of the following directives, space is provided below for you to write your own directives). _________ NO LIFE-Sto be followed if I am in a terminal condition and become unable to participate in decisions regarding my medical care. With respect to any life-sustaining treatment, I direct the following: (Initial selected and a notary public. TO MY FAMILY, PHYSICIANS, AND ALL THOSE CONCERNED WITH MY CARE: I, ______________________________________ willfully and voluntarily make this declaration as a directive document to your physician and your family. This form is entirely optional. If you choose to use this form, please note that the form provides signature lines for you, the two witnesses whom you haveodically to make sure it continues to reflect your wishes. You may amend or revoke this document at any time by notifying your physician and other health-care providers. You should give copies of this professional help to make sure the form does what you intend and is completed without mistakes. This document will remain valid and in effect until and unless you revoke it. Review this document perikind of treatment you want or do not want to receive. This document can control whether you live or die. Prepare this document carefully. If you use this form, read it completely. You may want to seekis document directs the medical treatment you are to receive in the event you are unable to participate in your own medical decisions and you are in a terminal condition. This document may state what a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION This is an important legal document. Thocal attorney is always recommended when dealing with Information & Instructions ­ Page 2 estate planning matters. Any possible tax consequences arising out of this document should be discussed withtate 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 make sure it fits your particular situation. Advice from a lility for 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 sprovider shall make the revocation a part of the 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 suitabt regard to the declarant's mental or physical condition. A revocation is effective upon communication to the attending physician or other health-care provider. The attending physician or health-care ly with the transfer requirements of § 34-12D-11. 34-12D-8. Revocation of declaration -- Medical record to contain revocation. A declarant may revoke a declaration at any time and in any manner withouegarding administration of life-sustaining treatment. If the declaration becomes operative, the attending physician and other health-care providers shall act in accordance with the declaration or compomes operative. A declaration becomes operative when the declarant is determined by the attending physician and one other physician to be in a terminal condition and no longer able to make decisions rtate which would apply in the absence of a declaration. 34-12D-3. Declaration -- Sample form. A declaration may, but need not, be in the following form (see form below): 34-12D-5. When declaration bec declarant's preferences with respect to artificial nutrition and hydration, whether artificial nutrition and hydration is to be provided, withheld, or withdrawn shall be governed by the law of this sration. A declaration shall state the declarant's preferences regarding whether the declarant wishes to receive or not receive artificial nutrition and hydration. If the declaration does not state the signed by the declarant, or another at the declarant's direction, and witnessed by two adult individuals. The signing may be in the presence of a notary public who shall thereafter notarize the declaD-2. Declaration -- Requirements as to execution. A competent adult may at any time execute a declaration governing the withholding or withdrawal of life-sustaining treatment. The declaration shall be based on Title 34 Chapter 12D Section 34-12D-2 et. Seq. of the South Dakota Code. For your convenience, we have included useful excerpts from the South Dakota Statutes relating to Living Wills. 34-12Information and Instructions South Dakota Living Will This package contains (1) Information and Instruction for South Dakota Living Will; (2) South Dakota Living Will. This South Dakota Living Will is South Dakota