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West Virginia __________________________ Notary Public 2 have this day acknowledged the same before me. Given under my hand this ______ day of ______, 20__. My commission expires:______________________________________ _________________________________________________ and __________________________________________________________________, as witnesses, whose names are signed to the writing above bearing date on the _______________ day of _______, 20____,________, a Notary Public of said County, do certify that ___________________________________________________________________, as principal, and _______________________________________________________hone: _______________________________________ Date:_________________________________________ STATE OF WEST VIRGINIA _______________________________ COUNTY OF ) ) ) ) I, __________________________________________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ P__________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date:_____principal's attending physician or the principal's medical power of attorney representative or successor medical power of attorney representative under a medical power of attorney. ___________________o any portion of the estate of the principal to the best of my knowledge under any will of principal or codicil thereto, or directly financially responsible for principal's medical care. I am not the ess 1 I did not sign the principal's signature above for or at the direction of the principal. I am at least eighteen years of age and am not related to the principal by blood or marriage, entitled t________________________________________________________ Signed _________________________________________________________________ _________________________________________________________________ Addrd as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences resulting from such refusal. I understand the full import of this living will. ________________________________________________________________________________ _____________________________________________________________________________ It is my intention that this living will be honoreI want or refuse certain treatments.) _____________________________________________________________________________ _____________________________________________________________________________ ______t tube feedings, breathing machines, cardiopulmonary resuscitation, dialysis and mental health treatment may be placed here. My failure to provide special directives or limitations does not mean that r medical procedures necessary to keep me comfortable. I want to receive as much medication as is necessary to alleviate my pain. I give the following SPECIAL DIRECTIVES OR LIMITATIONS: (Comments abouat would serve solely to prolong the dying process or maintain me in a persistent vegetative state be withheld or withdrawn. I want to be allowed to die naturally and only be given medications or otheal condition or to be in a persistent vegetative state (I am unconscious and am neither aware of my environment nor able to interact with others), I direct that life-prolonging medical intervention thbe prolonged under the following circumstances: If I am very sick and not able to communicate my wishes for myself and I am certified by one physician, who has personally examined me, to have a terminck and not able to communicate my wishes for myself. In the absence of my ability to give directions regarding the use of life-prolonging medical intervention, it is my desire that my dying shall not __________(month, year). I,_______________________________________________________________, being of sound mind, willfully and voluntarily declare that I want my wishes to be respected if I am very siase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com STATE OF WEST VIRGINIA Living Will Living will made this _____________________day of ___________ a local attorney 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 purchom 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 make sure it fits your particular situation. Advice fromitability 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 frvalid direction and to this end the directions in the living will are severable. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suisions of this article. Should any of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the living will which can be given effect without the insation, does not constitute the unauthorized practice of law. (g) The living will may, but need not, be in the following form and may include other specific directions not inconsistent with other provsocial workers, social service agencies, senior citizens centers, hospitals, nursing homes, personal care homes, community care facilities or any other similar person or group, without separate compenal power of attorney or living will. (f) The provision of living will or medical power of attorney forms substantially in compliance with this article by health care providers, medical practitioners, ven assistance in completing such forms if the person desires: Provided, That under no circumstances may admission to a health care facility be predicated upon a person having completed either a mediccal records. (e) At the time of admission to any health care facility, each person shall be advised of the existence and availability of living will and medical power of attorney forms and shall be giney, or the revocation of a living will or medical power of attorney, shall make the living will, medical power of attorney or a copy of either or a revocation of either a part of the principal's medil power of attorney or a revocation of the living will or medical power of attorney. An attending physician or other health care provider, when presented with the living will or medical power of attorresponsibility of the principal or his or her representative to provide for notification to his or her attending physician and other health care providers of the existence of the living will or medica or (4) any person who is an employee of an operator of a health care facility serving the principal and who is not related to the principal. Information & Instructions ­ Page 2 (d) It shall be the (1) A treating health care provider of the principal; (2) an employee of a treating health care provider not related to the principal; (3) an operator of a health care facility serving the principal;tive or successor medical power of attorney representative. (c) The following persons may not serve as a medical power of attorney representative or successor medical power of attorney representative:a named beneficiary of the principal's will; (4) Directly financially responsible for principal's medical care; (5) The attending physician; or (6) The principal's medical power of attorney representaed, That the validity of the living will or medical power of attorney shall not be affected when a witness at the time of witnessing such living will or medical power of attorney was unaware of being the direction of the principal; (2) Related to the principal by blood or marriage; (3) Entitled to any portion of the estate of the principal under any will of the principal or codicil thereto: Providbefore a notary public as provided in subsection (d) of this section. (b) In addition, a witness may not be: (1) The person who signed the living will or medical power of attorney on behalf of and at o; (3) dated; (4) signed in the presence of two or more witnesses at least eighteen years of age; and (5) signed and attested by such witnesses whose signatures and attestations shall be acknowledged this article shall be: (1) In writing; (2) executed by the principal or by another person in the principal's presence at the principal's express direction if the principal is physically unable to do sing a living will or medical power of attorney. (a) Any competent adult may execute at any time a living will or medical power of attorney. A living will or medical power of attorney made pursuant to l is based on Chapter 16 Section 30-4 et. Seq. of the West Virginia Code. For your convenience, we have included useful excerpts from the West Virginia Codes relating to Living Wills. §16-30-4. ExecutInformation and Instructions West Virginia Living Will This package contains (1) Information and Instruction for West Virginia Living Will; (2) West Virginia Living Will. This West Virginia Living Wil West Virginia