Statutory Declaration in Conformance with Wyoming Living Will Law.  Wyoming Statutes 35-22-102

DECLARATION OF _______________________

Declaration made this __________ day of ______________ 20_____. I, ________________, being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare: 

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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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

If, in spite of this declaration, I am comatose or otherwise unable to make treatment decisions for myself, I HEREBY designate ______________ to make treatment decisions for me. 

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 physicians 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. 

________________________________________ 

City of residence: ____________
County of residence: __________
State of Residence: ___________

Date: _______________________________________ 
                           
The Declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the Declarant’s signature above for or at the declaration of the Declarant. I am not related to the Declarant by blood or marriage, entitled to any portion of the estate of the Declarant according to the laws of in testate succession or under any will of Declarant or codicil thereto, or directly financially responsible for Declarant’s medical care. 

Witness: _____________________________________________ 

Witness: _____________________________________________ 
Date: _____________________ 

Statutory Declaration in Conformance with Wyoming Living Will Law.  Wyoming Statutes 35-22-102
Review List

This review list is provided to inform you about this document in question and assist you in its preparation.  This simple Life Sustaining Declaration is valid in Wyoming. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1.	Make multiple copies.  Give one to your doctor (s), the local hospital, and have others available through your attorney and family.  Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best.  So be sure they are available to the appropriate people easily, when needed.