Fillable CA Aid In Dying Request Interpreter Declaration (Death With Dignity)

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CA Aid In Dying Request Interpreter Declaration (Death With Dignity)

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The CA Aid In Dying Request Interpreter Declaration (Death With Dignity) form is 1 page long and contains:

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  • 19 other fields

Country of origin: US
File type: PDF

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REQUEST FOR AN AID-IN-DYING - INTERPRETER DECLARATION
I,
__________________________________________,
am fluent in English and
___________________.
NAME OF INTERPRETER
TARGET LANGUAGE
________________________
at approximately
______________,
DATE
TIME
I read the “Request for an Aid-In-Dying Drug to End My Life” to
______________________________________________________
in
____________________.
NAME OF PATIENT/QUALIFIED INDIVIDUAL
TARGET LANGUAGE
Mr./Ms.
___________________________________________________________________________
NAME OF PATIENT/QUALIFIED INDIVIDUAL
affirmed to me that he/she understood the content of this form and affirmed his/her desire to sign this
form under his/her own power and volition and that the request to sign the form followed consultations
with an attending and consulting physician.
I declare that I am fluent in English and
___________________________________________________
TARGET LANGUAGE
and further declare under penalty of perjury that the foregoing is true and correct.
Executed at
_______________________________,
______________________,
_______________
CITY
COUNTY
STATE
on this
_______________
of
______________________,
_________.
DAY OF MONTH
MONTH
YEAR
_______________________________________
INTERPRETER SIGNATURE
_______________________________________
INTERPRETER PRINTED NAME
_______________________________________
_____________________
____
____________
INTERPRETER STREET ADDRESS
CITY
STATE
ZIP CODE
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CA Aid In Dying Request Interpreter Declaration (Death With Dignity)

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Completed 11 March 2021

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