Bijlage 4 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; I did / did not* receive an advance directive signed by the deceased; in connection with this death, I did / did not* receive 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 consulted independent physician; I am not convinced that the death was due to natural causes. 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: naam voornamen (voluit) geboren op te , gewoond hebbende te , overleden op ; persoonlijk te hebben geschouwd; verklaart dat de behandelend arts van de overledene hem heeft medegedeeld dat de dood is ingetreden ten gevolge van de toepassing van leven