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					                    DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT
                                                                                  , being of sound mind and at least eighteen years of age,

direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that:

               1. If at any time my attending physician and one other qualified physician certify in writing that:
                    a. I have an injury, disease, or illness which is not curable or reversible and which, in their judgment,
                          is a terminal condition; and
                    b. For a period of seven consecutive days or more, I have been unconscious, comatose, or otherwise
                         incompetent so as to be unable to make or communicate responsible decisions concerning my
                         person; then
                    I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and
                    withheld pursuant to the terms of this declaration; it being understood that life-sustaining procedures
                    shall not include any medical procedure or intervention for nourishment considered necessary by the
                    attending physician to provide comfort or alleviate pain. However, I may specifically direct, in accord-
                    ace with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of
                    this declaration.

           2. In the event that the only procedure I am being provided is artificial nourishment, I direct that one of the
                following actions be taken:
                a. Artificial nourishment shall not be continued when it is the only procedure being provided; or

                  b. Artificial nourishment shall be continued for                                       days when it is the only procedure
                      being provided; or

                        Artificial nourishment shall be continued when it is the only procedure being provided.

           3. I execute this declaration, as my free and voluntary act on




                                                                            By


    The foregoing instrument was signed and declared by
 to be his/her declaration, in the presence of us, who, in his/her presence, in the presence of each other, and at his/her
 request, have signed our names below as witnesses, and we declare that, at the time of the execution of this instru-
 meant, the declarant according to our best knowledge and belief, was of sound mind and under no constraint or undue
 influence .

    Dated at                                                   , Colorado, this             day of                                     19



                                                     Signature of Witness                                                              Signature of Witness


                    Print or Type Name and Address                                                   Print far Type Name and Address




                         STATE OF COLORADO

                               County of                                             ss

    SUBSCRIBED and sworn to before me by                                                                                      , the declrarant, and
                                                               , and                                                            , witnesses, as the
 voluntary act and deed of the declrarant, this                                  day of                                        , 19


 Witness my hand and seal.
                                                   Attorney William Bronchick’s
                                                 WEALTH PROTECTION LIBRARY
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   “EZ” Customer Order Form                                                                Telephone Orders:
                                                                                           Toll Free 1-800-655-3632
   Name_____________________________________________________________________________

   E-mail ________________________________ Daytime Phone _____________________________     Fax Orders:
                                                                                           Toll Free 1-888-665-3742
   Shipping Address ___________________________________________________________________

   City _____________________________________________ ST _____________ Zip ____________    Internet Orders:
                                                                                           www.legalwiz.com/books.htm
      Enclosed is my check payable to “Legalwiz Publications”
                                                                                           Mail Orders: Legalwiz Publications
      Please bill my MC/VISA _______________________________________________ Ex ________
                                                                                           2620 S. Parker Rd #272
                                                                                           Aurora, CO 80014

				
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posted:2/24/2008
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