DECLARATION AS PROVIDED BY ALASKA STATUES, SEC 18.12.010 


                       DECLARATION of ______________ 

     If I should have an incurable or irreversible condition that 
will  cause  my death within a relatively short time,  it  is  my 
desire  that my life not be prolonged by administration of  life- 
sustaining procedures. 

    If my condition is terminal and I am unable to participate in 
decisions  regarding my medical treatment, I direct my  attending 
physician to withhold or withdraw procedures that merely  prolong 
the  dying  process  and are not necessary to my  comfort  or  to 
alleviate pain.  

    I do [ ] do not [ ] desire that nutrition or hydration (food  
and water) be provided by gastric tube or intravenously if  
necessary. 
Signed this______ day of _____________________, 19______________ 
Signature: 


________________________________________________________________ 


Place of signing: _____________________




     The  declarant  is  known to me and  voluntarily  signed  or 
voluntarily  directed  another  to  sign  this  document  in   my 
presence 
Witness: 

________________________________________________________________ 
Signature 

Address: 


________________________________________________________________ 
Signature 

Address: 
State of _________________________ 
__________________________________ Judicial District 


    The foregoing instrument was acknowledged before me this 
________________________________________, 19_________________ by 
___________________.

                           




                       _________________________________________ 

                       Signature of person taking acknowledgment