Mississippi Living Will Template
This Living Will is created in accordance with the Mississippi Code Annotated, Section 41-41-201 et seq. It allows you to express your wishes regarding medical treatment in the event you become unable to communicate those wishes yourself.
Instructions: Fill in the blanks with your personal information where indicated.
Personal Information:
- Full Name: ___________________________________
- Date of Birth: ________________________________
- Address: _____________________________________
- City, State, Zip Code: ______________________
Designation of Health Care Agent:
I, _______________________________, hereby designate the following individual as my health care agent:
- Name of Agent: ___________________________________
- Address of Agent: ________________________________
- Phone Number of Agent: _________________________
Living Will Declaration:
If I become terminally ill or permanently unconscious, I direct that my health care providers follow these instructions:
- I do not wish to receive life-sustaining treatment if I am unable to make my own medical decisions.
- I wish to receive palliative care to keep me comfortable.
- If I am in a state of irreversible coma, I do not wish to receive any life-sustaining treatment.
Signatures:
By signing below, I affirm that I am of sound mind and that I understand the contents of this Living Will.
Signature: ___________________________________
Date: ______________________________________
Witnesses:
This document must be witnessed by two individuals who are not related to you and who are not entitled to any part of your estate.
- Witness 1 Name: _______________________________
- Witness 1 Signature: __________________________
- Date: ______________________________________
- Witness 2 Name: _______________________________
- Witness 2 Signature: __________________________
- Date: ______________________________________