(1) which expresses substantially in the form set forth in § 44-77-50 a desire of the declarant that no life-sustaining procedures be used to prolong dying if his condition is terminal or if he is permanently unconscious and states that the declarant is aware that the declaration authorizes a physician to withhold or withdraw life-sustaining procedures;

(2) which has been dated and signed by the declarant in the presence of an officer authorized to administer oaths under the laws of the state where the signing occurs and in the presence of two witnesses, one of whom may be the officer authorized to administer oaths, who state in an affidavit as set forth in § 44-77-50 that, to the extent they have knowledge of their status, they are not related to the declarant by blood, marriage, or adoption, either as a spouse, lineal ancestor, descendant of the parents of the declarant, or spouse of any of them, not directly financially responsible for the person‘s medical care, not entitled to a portion of the estate of the declarant upon his decease under a will of the declarant then existing or as an heir by intestate succession, and not a beneficiary of a life insurance policy of the declarant, and who state that no more than one witness is an employee of a health facility in which the declarant is a patient and that no witness to the declaration is the attending physician or an employee of the attending physician or a person who has a claim against a portion of the estate of the declarant upon his decease at the time of the execution of the declaration;

(3) which, if the declarant is a patient in a hospital or a resident in a nursing care facility at the time the declaration is executed, has been witnessed by an ombudsman as designated by the State Ombudsman, Office of the Governor, with the ombudsman acting as one of the two witnesses and having the same qualifications as a witness as provided in this section. The intent of this item is to recognize that some residents in nursing care facilities may be so insulated from a voluntary decision-making role, by virtue of the custodial nature of their care, as to require special assurance that they are capable of wilfully and voluntarily executing a declaration; and

(4) which accompanying affidavit has been subscribed by the two witnesses and sworn to by at least one of the two witnesses in the presence of the declarant, and of each other, and of an officer authorized to administer oaths under the laws of the state where the signing occurs. A witness to a declaration who is also an officer authorized to administer oaths under the laws of this State may notarize the signature of the other witness of the declaration in the manner provided by § 44-77-50.