Center for Health Statistics

Death with Dignity Act

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Forms Received Washington Death with Dignity Act Forms Received by Department of Health DOH Publication Number Form Name Number Received in 2009 422-063 Written Request for Medication to End My Life in a Humane and Dignified Manner form 51 422-064 Attending Physician's Compliance form 52 422-065 Consulting Physician's Compliance form 53 422-066 Psychiatric/Psychological Consultant's Compliance form 3 422-067 Pharmacy Dispensing Record form 49 422-068 Attending Physician's After Death Reporting form 32

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Last Update : 11/12/2009 09:48 AM