CALIFORNIA DECLARATION

	If I should have an incurable and irreversible condition that has been diagnosed by two physicians and that will result in my death within a relatively short time without the administration of life-sustaining treatment or has produced an irreversible coma or persistent vegetative state, and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Natural Death Act of California, to withhold or withdraw treatment, including artificially administered nutrition and hydration, that only prolongs the process of dying or the irreversible coma or persistent vegetative state and is not necessary for my comfort or to alleviate pain.

 	If I have been diagnosed as pregnant, and that diagnosis is known to my  physician, this declaration shall have no force or effect during my pregnancy.

	Other instructions:
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Signed this _____ day of _____________________, 19_______.

	Signature ________________________________________________

	Address __________________________________________________

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	The declarant voluntarily signed this writing in my presence. I am not a health care provider, an employee of a health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, or an employee of an operator of a residential care facility for the elderly.

	Witness __________________________________________________

	Address __________________________________________________

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	The declarant voluntarily signed this writing in my presence. I am not entitled to any portion of the estate of the declarant upon his or her death under any will or codicil thereto of the declarant now existing or by operation of law. I am not a health care provider, an employee of a health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, or an employee of an operator of a residential care facility for the elderly.

	Witness __________________________________________________

	Address __________________________________________________

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STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN

	I further declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and that I am serving as a witness as required by Section 7178 of the Health and Safety Code.

Signature: ___________________________________