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[You' should' consider' completing' a' new' Living' Will' Declaration' if' your' medical'
condition'changes'or'if'you'later'decide'to'complete'a'Health'Care'Power'of'Attorney.'
If'you' have' both'a' Living' Will' Declaration' and'a' Health ' Care'Power' of'Attorney,'you'
should' keep' copies' of' these' documents' together.' Bring' your' document(s)' with' you'
whenever'you'are'a'patient'in'a'health'care'facility'or'when'you'update'your'medical'
records'with'your'physician.]''''''
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'-4/$%-!.6'41?26/$&!/4!'$U2!<22E.6%&L![You'can'refuse'or'discontinue'a'feeding'tube,'or'
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or'hydration.]'
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:&"*'*/#"*&.2O![Note:''You'do'not'need'to'name'anyone.'If'no'one'is'named,'the'law'requires''
your'attending'physician'to'make'a'reasonable'effort'to'notify'one'of'the'following'persons'in''
the'order'named:''your'guardian,'your'spouse,'your'adult'children'who'are'available,'your''
parents,'or'a'majority'of'your'adult'siblings'who'are'available.]!!
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Special(InstructionsO%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%E9%D5#/*.A%;9%*.*"*#52I%2*A.#"=1$I%/)$/J%&1%&")$1%;#1J%*.%")*2%K&LI%M%2D$/*'*/#559%
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Additional(instructions(or(limitations.(
[If'the'space'below'is'not'sufficient,'you'may'attach'additional'pages.''
If'you'do'not'have'any'additional'instructions'or'limitations,'write'“None”'below.]'
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[The' “anatomical' gift”' langu age' provided' below' is' required' by' ORC' §2133.07(C).' Donate' Life'
Ohio'recommends'that'you'indicate'your'authorization'to'be'an'organ,'tissue'or'cornea'donor'at'
the' Ohio' Bureau' of' Motor' Vehicles' when' receiving' a' driver' license' or,' if' you' wish' to' place'
restrictions'on'your'donation,'on'a'Donor'Registry'Enrollment'Form'(attached)'sent'to'the'Ohio'
Bureau'of'Motor'Vehicles.]''
[If'you'use'this'living'will'to'declare'your'authorization,'indicate'the'organs'and/or'tissues'you'
wish'to'donate'and'cross'out'any'purposes'for'which'you'do'not'authorize'your'donation'to'be'
used.'Please'see'the'attached'Donor'Registry'Enrollment'Form'for'help'in'this'regard.''In'all'
cases,'let'your'family'know'your'declared'wishes'for'donation.]
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[The'following'persons'CANNOT'serve'as'a'witness'to'this'Living'Will'Declaration:'
• Your'agent'in'your'Health'Care'Power'of'Attorney,'if'any;'
• 'The'guardian'of'your'person'or'estate,'if'any;
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!,-./!>.?.6%[email protected]! ! :1%2!02?26!/<!02?26!
• Any'alternate'agent'or'guardian,'if'any;'
• 'Anyone'related'to'you'by'blood,'marriage'or'adoption'(for'example,'your''
spouse'and'children);''
• Your'attending'physician;'and''
• The'administrator'of'the'nursing'home'where'you'are'receiving'care.]'
'
I(attest(that(the(Declarant(signed(or(acknowledged(this(Living(Will(Declaration(in(my(
presence,(and(that(the(Declarant(appears(to(be(of(sound(mind(and(not(under(or(subject(to(
duress,(fraud(or(undue(influence.((
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OR,(if(there(are(no(witnesses,(
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©'August'2016.'May'be'rep rin ted 'a nd 'co p ied 'fo r'us e'b y'th e 'pu b lic,'at to rne y s,'m e dic al'a n d'o ste o pa th ic'p h ys icia ns ,'ho sp ita ls,'
bar'associations,'medical'societies'and'nonprofit'associations'and'organizations.'It'may'not'be'reproduced'commercially'for'
sale'at'a'profit.