DECLARATION PROVIDED BY COLORADO MEDICAL TREATMENT DECISION ACT,
COLORADO STATUTES 15-18-104 


         DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT 

I _____________, being of sound mind and at least eighteen years 
of age, direct that my life shall not be artificially prolonged 
under the circumstances set forth below and hereby declare that: 

1. If at any time my attending physician and one other physician
certify in writing that: 


    a. I have an injury, disease, or illness which is not curable
or reversible and which, in their judgment, is a terminal
condition; and 


    b. For a period of forty-eight consecutive hours or more, I
have been unconscious, comatose, or otherwise incompetent so as to
be unable to make or communicate responsive decisions concerning
my person; then, 


    I direct that life-sustaining procedures shall be withdrawn
and withheld, it being understood that life-sustaining procedures
shall not include any medical procedure or intervention for
nourishment or considered necessary by the attending physician to
provide comfort or alleviate pain. 

2. I execute this declaration, as my free and voluntary act, 

this ___________________ day of _____________________, 19______. 



By ___________________________________ 

___________________________, Declarant 


    The foregoing instrument was signed and declared by ________
_______ to be his declaration, in the presence of us, who, in his 
presence, in the presence of each other, and at his request  have
signed our names below as witnesses, and we declare that, at  the
time of the execution of this instrument, the declarant, 
according to our best knowledge and belief, was of sound mind and
under no constraint or undue influence. 


    Dated at _______, _______, this ___________ 

day of _____________________________________, 19________. 
                           





________________________________________________________ 
Name and address 





________________________________________________________ 
Name and address 

STATE OF COLORADO 

COUNTY OF ______________ 


    Subscribed and sworn to before me by _________________,

the declarant, and __________________________________, and  

____________________________________, witnesses, as the voluntary 

act and deed of the declarant, this ________________ day of  

____________________  19________. 






                        ________________________________________ 
                        Notary Public