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(zip) Social Security Number (phone) Willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am mentally or physically incapacitated and (Initial) I have a terminal condition, or (Initial) I have an end-stage condition, or (Initial) I am in a persistent vegetative state (Initial) I do not want to be tube fed and if my attending or.

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