Bijlage 3 Regeling modelformulieren levensbeëindiging op verzoek en hulp bij zelfdoding BES

Regeling modelformulieren levensbeëindiging op verzoek en hulp bij zelfdoding BES

To the person or committee referred to in section 5 of the Death Certificates (Bonaire, St Eustatius and Saba) Act; I the undersigned, as the physician appointed by the island executive pursuant to section 4 of the Death Certificates (Bonaire, St Eustatius and Saba) Act declare that I have personally conducted an external post-mortem examination of: name given names (in full) born in on ; residing at , died on ; I have been notified by the deceased’s attending physician that the death occurred as a result of termination of life on request / the provision of assistance with suicide*; I have verified how and by what means the deceased’s life was terminated; I have received a well substantiated report from the attending physician on compliance with the due care criteria set out in section 2 of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act; in connection with this death, I have/ have not* received from the attending physician an advance directive signed by the deceased; in connection with this death, I have / have not* received from the attending physician a written opinion drawn up by the independent physician consulted; I have enclosed with this form a report on compliance with the due care criteria set out in section 2 of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act and, if received, the deceased person’s advance directive and the written opinion of the independent physician consulted; I am not convinced that the death was due to natural causes and have therefore notified the registrar of births, deaths, marriages and registered partnerships of the public body where the deceased person was resident. Remarks: (date) (signature) * delete as appropriate Aan de in artikel 5 van de Wet verklaringen van overlijden BES bedoelde persoon of commissie ; De ondergetekende, op grond van artikel 4 van de Wet verklaringen van overlijden BES door het bestuurscollege aangewezen geneeskundige; verklaart het lijk van