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 2009 2010 422-063 Written Request for Medication to End My Life in a Humane and Dignified Manner form 64 6 422-064 Attending Physician's Compliance form 65 6 422-065 Consulting Physician's Compliance form 67 7 422-066 Psychiatric/Psychological Consultant's Compliance form 4 0 422-067 Pharmacy Dispensing Record form 63 2 422-068 Attending Physician's After Death Reporting form 42 3

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Last Update : 01/21/2010 08:07 AM