STATE OF NORTH CAROLINA
COUNTY OF CARTERET

DECLARATION OF A DESIRE
FOR A NATURAL DEATH

             I ____________________________________________, being of sound mind, desire that, as specified below, my life not be pronged by extraordinary means or by artificial nutrition or hydration if my condition is determined to be terminal and incurable or if I am diagnosed as being in a persistent vegetative state. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration, in accordance with my specifications set forth below: (Initial any of the following, as desired).

____   If my condition is determined to be terminal and incurable, I authorize the following:

            ____            My physician may withhold or discontinue extraordinary means only.

             ____            In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.

____   If my physician determines that I am in a persistent vegetative state, I authorize the following:

             ____            My physician may withhold or discontinue extraordinary means only.

            ____            In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either nutrition or hydration, or both.

This the ____________ day of ______________ 20_____

Signature________________________________________

            I hereby state that the declarant, __________________ being of sound mind signed the above declaration in my presence and that I am not related to the declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the declarant under any existing Will or Codicil of the declarant, or as an heir under the Intestate Succession Act if the declarant died on this date without a Will. I also state that I am not the declarant’s attending physician or an employee of the declarant’s attending physician or a employee of a heath facility in which the declarant is a patient or an employee of a nursing home or any group care home where the declarant resides. I further state that I do not now have any claim against the declarant.

                        Witness ____________________________

                        Witness ____________________________

CERTIFICATE

I, ______________________________________, Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for __________ County hereby certify that __________________, the declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his/her Declaration of A Desire For A Natural Death, and that he/she had willingly and by voluntarily made and executed it as his/her free act and deed for the purposes expressed in it.

            I further certify that ____________ and ___________________________ witnesses, appeared before me and swore that they witnessed __________________ declarant, sign the attached declaration believing him/her to be of the sound mind; and also swore that at the time they witnessed the declaration (I) they were not related within the third degree to the declarant or to the declarant spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon the declarant’s death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at the time, and (iii), they were not a physician attending the declarant or an employee of the attending physician or an employee of a health facility in when the declarant was a patient or an employee of a nursing home or any group-care home in which the declarant resided, and (iv) they did not have a claim against the declarant. I further certify that I am satisfied as the genuineness and due execution of the declaration.

This _________ day of____________ 20 ________

  ____________________________

 Clerk (Assistant Clerk) of Superior

Court or Notary Public (circle one

 As appropriate) for the County of