Vermont Living Will
This document is a Living Will, sometimes known as an Advance Directive, prepared in accordance with the laws of the State of Vermont to outline the wishes of the undersigned regarding medical treatment in the event they are unable to communicate these wishes themselves.
Part 1: Information of the Declarant
Full Name: ___________________________________________________________
Date of Birth: ___________________________
Social Security Number: __________________________________________
Address: _____________________________________________________________
City: _________________________ State: Vermont Zip Code: _______________
Telephone Number: _____________________________
Part 2: Healthcare Directives
It is my wish that, should I be in a state of terminal condition, where the application of life-sustaining procedures would only serve to artificially prolong my dying process, I shall be permitted to die naturally and to only receive treatment that would provide comfort and relieve pain.
- I do not want life-sustaining treatment if I am in a persistent vegetative state or in a terminal condition where recovery is not expected, except as noted below:
- ______________________________________________________________
- I do or do not want artificial nutrition and hydration to be provided, unless I have specifically stated otherwise here:
- ______________________________________________________________
Part 3: Powers of Attorney for Health Care
I hereby appoint the following individual as my agent to make health care decisions on my behalf should I become incapable of making my own decisions:
Name: ___________________________________________________________
Relationship: ___________________________________________________
Primary Phone: ______________________ Alternate Phone: _________________
If my primary agent is unable, unwilling, or unavailable to act on my behalf, I appoint the following individual as my alternate agent:
Name: ___________________________________________________________
Relationship: ___________________________________________________
Primary Phone: ______________________ Alternate Phone: _________________
Part 4: Signature
This document is executed voluntarily and without any undue influence, on this _____ day of _______________, 20____.
__________________________________________
Signature of the Declarant
State of Vermont, County of _____________________
Subscribed and affirmed before me on this _____ day of _______________, 20____.
__________________________________________
Notary Public
My Commission Expires: _____________________