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Iowa Living Will Form

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Iowa Living Will Form
Iowa Living Will Form
THE IOWA STATE BAR ASSOCIATION
Official Form No. 122
FOR THE LEGAL EFFECT OF THE USE OF
THIS FORM, CONSULT YOUR LAWYER
© The Iowa State Bar Association 2011
IOWADOCS®
DECLARATION RELATING TO USE OF LIFE-SUSTAINING PROCEDURES
Revised April 2011
DECLARATION RELATING TO USE OF LIFE-SUSTAINING PROCEDURES
DECLARATION
(Living Will)
If I should have an incurable or irreversible condition that will result either in death within a relatively
short period of time or a state of permanent unconsciousness from which, to a reasonable degree of
medical certainty, there can be no recovery, it is my desire that my life not be prolonged by the
administration of life-sustaining procedures. If I am unable to participate in my health care decisions, I
direct my attending physician to withhold or withdraw life-sustaining procedures that merely prolong the
dying process and are not necessary to my comfort or freedom from pain.
YES__ NO__ In the event that medical professionals determine that I may be an organ donor, I
agree to the use of life-sustaining procedures, including a ventilator, for the sole purpose and time
period required to complete the organ donation. Nothing in this paragraph shall be construed to expand
or detract from the laws related to anatomical gifts as outlined in the Iowa Code, Chapter 142C. The
purpose of this paragraph is to practically and medically make organ donation possible.
Signed this ______day of __________________, _______.
____________________________
Signature of Declarant
_____________________________________
Type or Print Name of Declarant
_____________________________________ _____________________________________
Address, Street, City, State and Zip Date of Birth of Declarant
This Declaration must be witnessed by two persons or be notarized.
STATE OF IOWA , COUNTY OF _______________________
This instrument was acknowledged before me on _______________________________________, by
__________________________________________________________________________________.
___________________________________
, Notary Public
By signing this form I declare that I signed this form in the presence of the other witness and the
Declarant and I witnessed the signing by the Declarant or by another person acting on behalf of and at
the Declarant's direction.
_________________________________
Signature of 1
st
Witness
_________________________________
Signature of 2
nd
Witness
_________________________________
Type or Print Name of Witness
_________________________________
Type or Print Name of Witness
_________________________________
Street, City, State, Zip Code
_________________________________
Street, City, State, Zip Code
Iowa Living Will Form
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