#5001
@001 Please state the name of the declarant:
@002 Please state the city where signed:
@003 Please state the county where signed:
@004 Please state the state where signed: 
#end control section
#5001
/* Alabama Statutory declaration */


STATUTORY DECLARATION IN CONFORMANCE WITH ALABAMA NATURAL DEATH
ACT, AL.CODE 22-8A-4

                    DECLARATION OF @001



	Declaration made this __________ day of ________________

19________. I, @001, 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 hereby 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withheld or withdrawn, and that I be permitted to die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 too
provide me with comfort care.


	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.




________________________________________

@001


 City of residence: @002
 County of residence: @003
 State of residence: @004



			Date: __________________________________


	The declarant has been personally known to me and
I believe him or her to be of sound mind. I did not sign the
declarant's signature above for or at the declaration 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 or
under any will of declarant or codicil thereto, or directly
financially responsible for declarant's medical care.





Witness         ______________________________________________





Witness         ______________________________________________


Date: ___________________________________________