STATUTORY DECLARATION IN CONFORMANCE WITH VIRGINIA NATURAL DEATH

ACT VA. CODE SECTION 54-325.8:4

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 a terminal condition and my

attending physician has determined that there can be no recovery

from such condition and my death will is imminent, 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procedures be withheld or withdrawn, and that I be permitted to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 physician 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.

Signed:

________________________________________

City of residence: ______________

County of residence: ____________

State of residence: _____________

Date: _____________________

The declarant is known to me and I believe him or her to be of

sound mind.

Witness _________________________________________________

Witness _________________________________________________

Date: ___________________