Missouri Living Will Template
This Living Will is designed to comply with the requirements established under Missouri law. It allows you to outline your healthcare preferences in the event that you are unable to communicate these wishes yourself.
Effective Date: This Living Will shall become effective immediately upon execution.
Principal’s Information:
- Name: ____________________________________
- Address: __________________________________
- City: ______________ Zip Code: ____________
- Date of Birth: ____________________________
Healthcare Representative:
- Name: ____________________________________
- Address: __________________________________
- City: ______________ Zip Code: ____________
- Phone Number: ____________________________
Declaration: I, the undersigned, hereby declare that if I become unable to make my own healthcare decisions, the following is my wish regarding the withholding or withdrawal of life-sustaining treatments:
- If I am diagnosed with a terminal condition and I am unable to communicate my wishes, I request that all life-sustaining treatments be withheld or withdrawn.
- If I am in a state of persistent unconsciousness, I do not desire extraordinary measures to be taken to prolong my dying process.
Additional Instructions: You may include specific instructions about other medical treatments or care you wish to receive or withhold:
________________________________________________________________________
________________________________________________________________________
Signatures: This Living Will must be signed by the principal in the presence of two witnesses or a notary public, as required by Missouri law.
Signed this ____ day of ____________, 20___.
Principal’s Signature: ___________________________________________
Witness 1: ________________________________________
Witness 2: ________________________________________
Notary Public:
State of Missouri
County of __________________
Subscribed and sworn to before me on this ____ day of ____________, 20___.
Notary Signature: ________________________________
My commission expires: _________________________