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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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1993-08-01
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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procedures be withheld or withdrawn, and that I be permitted to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: ___________________