Declaration made this day of 18 September, 2017.
I, John Hagstrand, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially delayed.
If at any time I should have a terminal injury, disease, or condition, I direct that life-sustaining procedures and medicines be withheld or withdrawn, and that I be permitted to die naturally.
Please.
No pain killers.
No water. No nourishment.
No oxygen.
No comfort care.
In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration 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. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
Thank you
John Hagstrand