3228

LAWS OF MARYLAND

Ch. 832

in conformance with the provisions of paragraph (c)(1) of this
section a part of the declarant's medical records.

(c) (1) The declaration shall be substantially in the
following form:

"Declaration

If at any time I should have an incurable injury, disease,
or illness certified to be a terminal condition by two (2)
physicians who have personally examined me, one (1) of whom shall
be my attending physician, and the physicians have determined
that my death is imminent and will occur whether or not
life-sustaining procedures are utilized and where the application
of such procedures would serve only to artificially prolong the
dying process, I direct that such procedures be withheld or
withdrawn, and that I be permitted to die naturally with only the
administration of medication, the administration of food and
water, and the performance of any medical procedure that is
necessary to provide comfort care or alleviate pain. 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 right to control my medical care and
treatment.

Declaration made this _____ day of ___________ (month,

year). I,_______________________, being of sound mind,

willfully and voluntarily direct that my dying shall not be
artificially prolonged under the circumstances set forth in this
declaration:

I am legally competent to make this declaration, and I
understand its full import.

Signed________________________________

Address________________________________

Under penalty of perjury, we state that this declaration was

signed by _____________________ in the presence of the

undersigned who, at _______ request, in ____ presence, and in

the presence of each other, have hereunto signed our names and

witnessed this ___ day of __________ 19__, and declare: The

declarant is [personally] known to me, and I believe the
declarant to be of sound mind. I did not sign the declarant's
signature to this declaration. Based upon information and
belief, I am not related to the declarant by blood or marriage, a
creditor of the declarant, KNOWINGLY entitled to any portion of
the estate of the declarant under any existing testamentary