STATUTORY DECLARATION IN CONFORMANCE WITH DISTRICT OF COLUMBIA

NATURAL DEATH ACT OF 1981, D.C. CODE SECTION 6-2422

DECLARATION OF __________________

Declaration made this __________ day of ________________

19________. I ________________, being of sound mind, willfully

and voluntarily make known my desires that my dying shall not be

artificially prolonged under the circumstances set forth below,

do declare:

If at any time I should have an incurable injury, disease, or

illness certified to be a terminal condition by two physicians who

have personally examined me, one of whom shall be my attending

physician, and the physicians have determined that my death will

occur whether or not life- sustaining procedures are utilized and

where the application of life-sustaining procedures would serve

only to artificially prolong the dying process, I direct that such

procedures be withheld or withdrawn, and that I be permitted to

die naturally with only the administration of medication or the

performance of any medical procedure deemed necessary to provide

me with comfort care or to alleviate pain.

In the absence of my ability to give directions regarding the use

of such life-sustaining procedures, it is my intention that this

declaration shall be honored by my family and physicians as the

final expression of my legal right to refuse medical or surgical

treatment and accept the consequences from such refusal.

I understand the full import of this declaration and I am

emotionally and mentally competent to make this declaration.

________________________________________

City of residence: _____________________

County of residence: __________________

State of residence: ____________________

Date: __________________________________

I believe the declarant to be of sound mind. I did not sign the

declarant's signature above for or at the direction of the

declarant. I am not related to the declarant by blood or marriage,

entitled to any portion of the estate of the declarant according

to the laws of intestate succession of the District of Columbia or

under any will of declarant or codicil thereto, or directly

financially responsible for declarant's medical care. I am not the

declarant's attending physician, an employee of the attending

physician, or an employee of the health facility in which the

declarant is a patient.

Witness ___________________________________________

Witness ___________________________________________

Date: ___________________