#5006
@001 Please enter the name of the declarant:
@002 Please enter the city where signed:
@003 Please enter the county where signed [if D.C. state D.C]:
@004 Please enter the state where signed [if D.C. enter D.C.]:
#end control section
#5006
/*District of Columbia form*/
STATUTORY DECLARATION IN CONFORMANCE WITH DISTRICT OF COLUMBIA
NATURAL DEATH ACT OF 1981, D.C. CODE SECTION 6-2422


             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 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withheld or withdrawn, and that I be permitted to die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.




________________________________________
@001

City of residence: @002

County of residence: @003

State of residence: @004





        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: ___________________