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procedures be withheld or withdrawn, and that I be permitted to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