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Declaration (Living Will - Designating Other) Form. This is a Montana form and can be use in Living Will Statewide.
Tags: Declaration (Living Will - Designating Other), Montana Statewide, Living Will
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
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Calendar No.
A declaration that designates another individual to make decisions governing the withholding OI
:
withdrawal of life-sustaining treatment may,Plaintiff(s) be in the following form:
but need not,
JUDICIAL SUBPOENA
-against-
:
DECLARATION
:
If I should have an incurable and irreversible condition that, without the administration of life-
:
sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively
Defendant(s)
:
. . . . . short. time . and. I. am .no . longer . able . . make .decisions .regarding . my . medical treatment, I appoint
. . . . . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . .
or, if he or she is not reasonably available or is unwilling to serve,
THE PEOPLE OF THE STATEmakeNEW YORK behalfregarding
, to OF decisions on my
TO
withholding or withdrawal of
treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain,
pursuant to the Montana Rights ofthe Terminally 111
Act.
If the individual I have appointed is not reasonably available or is unwilling to serve, I direct my
GREETINGS:
attending physician, pursuant to the Montana Rights of the Terminally Ill Act, to withhold or withdraw
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
treatment
,
the Honorable that only prolongs the process of dying andthenot necessary for my comfort or to alleviate pain.
at is
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Signed thisday of
or adjourned date, to testify and give evidence as a,20witness in this action on the part of the
NXIX
Address
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
The de&rant voluntarily signed this document in my presence.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
Witness Name
Address
(Attorney must sign above and type name below)
Attorney(s) for
Witness Name
Address
Name and address of designee:
NZUne
Address
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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