STATE OF GEORGIA      	 )

				 )	LIVING WILL

	   COUNTY OF  __________)



	Living Will made this ____________ day of_________ , 19____.





	I, ___________________, being of sound mind, willfully

 and voluntarily make known my desires that my life shall not be 

prolonged under the circumstances set forth below and do declare:

	1.  If at any time I should (check each option desired): 

		( ) have a terminal condition,

		( ) become in a coma with no reasonable 

expectation of regaining consciousness, or

                                ( ) become in a persistent vegetative 

state with no reasonable expectation of regaining significant

 cognitive function, as defined in and established in accordance

 with the procedures set forth in paragraphs (2), (9), and (13) of

 Code Section 31-32-2 of the Official Code of Georgia Annotated,

 I direct that the application of life-sustaining procedures to my

 body (check the option desired):

		( ) including nourishment and hydration,

		( ) including nourishment but not hydration, or

		( ) excluding nourishment and hydration, be

 withheld or withdrawn and that I be permitted to die;

	2.  In the absence of my ability to give directions

 regarding the use of such life-sustaining procedures, it is my

 intention that this Living Will shall be honored by my family and

 physician(s) as the final expression of my legal right to refuse

 medical or surgical treatment and accept the consequences

 from such refusal;

	3.  I understand that I may revoke this Living Will 

at any time; and

	4.  I understand the full import of this Living Will,

 and I am at least eighteen (18) years of age and am

 emotionally and mentally competent to make this Living Will.

	5.  If I am female and I have been diagnosed as pregnant,

 this Living Will shall have no force and effect unless the fetus is 

not viable and I indicate by initialing after this sentence that I want

 this Living Will to be carried out.  (Initial)





		_____________________________(L.S.)

						



______________ (City), ____________ (County),





 _____________ (State of Residence)



	I hereby witness this Living Will and attest that:

	(1)  The declarant is personally known to me, and

 I believe the declarant to be at least eighteen (18) years of

 age and of sound mind;

	(2)  I am at least eighteen (18) years of age;

	(3)  To the best of my knowledge, at the time of the execution

 of this Living Will, I:

		(A)  Am not related to the declarant by blood

 or marriage;

		(B)  Would not be entitled to any portion

 of the declarant's estate by any Will or by operation of law under 

the rules of descent and distribution of this state;

		(C)  Am not the attending physician of declarant or

 an employee of the attending physician or an employee of this hospital

 or skilled nursing facility in which declarant is a patient;

		(D)  Am not directly financially responsible for the

 declarant's medical care; and

		(E)  Have no present claim against any portion

 of the estate of the declarant.

	(4)  Declarant has signed this document and in my presence 

as above instructed, on the date above first shown.



	Witness _________________________



	Address _________________________



	        _________________________



	Witness _________________________



	Address _________________________



	         _________________________





	Additional witnesses required when living will 

is signed in a hospital or skilled nursing facility.



	I hereby witness this living will and attest that

 I believe the declarant to be of sound mind and to have

 made this living will willingly and voluntarily.



Witness: ________________________________________

					    	



Medical director of skilled nursing facility 

or staff physician not participating in care of the patient or chief 

of the hospital medical staff or staff physician or hospital 

designee not participating in care of the patient.