Living Will (Rev. 1339E80)
District of Columbia Declaration
Declaration made this 16 day of June, 2016
I, Connor Delaney , 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 (2) 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withdrawn, and that I be permitted to die naturally with only the administration of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 physician(s) as the final expression of my legal right to refuse
medical or surgical treatment and I 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.
SIGNATURE
Signed: ___________________________________________
Date: _________________________________
Address: 345 Fullview Drive, Washington, DC 22222
WITNESS
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 at least eighteen (18)
years of age and am not related to the declarant by blood, marriage, or domestic
partnership, 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 the
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