North Carolina Living Will Template
This document, known as a Living Will, is designed under the authority of the North Carolina Advance Directive for a Natural Death Act. It allows individuals to express their wishes regarding life-prolonging measures in the event they are unable to communicate their decisions due to a terminal condition or a state of permanent unconsciousness. By completing this template, you can ensure your healthcare preferences are known and respected.
Personal Information
Full Legal Name: ___________________________
Date of Birth: ___________________________
Address: __________________________________
City: __________________ State: NC Zip Code: ________
Declaration
I, _____________________, being of sound mind, do hereby willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
Life-Prolonging Measures
If at any time I should have an incurable or irreversible condition that will result in my death within a relatively short time, I direct that such measures that would only prolong the dying process or maintain me in a state of permanent unconsciousness be withheld or withdrawn, and that I be permitted to die naturally. I understand by using this Living Will that I am authorizing my attending physician to withhold or withdraw such procedures.
Special Provisions and Limitations
If you wish to include special provisions or limitations to this Living Will, please outline them below:
________________________________________________________________
________________________________________________________________
Signature
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
Date: ____________________________
Signature: ___________________________
Print Name: ___________________________
Witnesses
This Living Will must be witnessed by two qualified individuals who are present when this directive is signed. Witnesses cannot be related to you by blood or marriage, entitled to any portion of your estate, your attending physician, or employees of your attending healthcare provider.
Witness 1
Name: ___________________________
Date: ____________________________
Signature: ___________________________
Witness 2
Name: ___________________________
Date: ____________________________
Signature: ___________________________