New York Living Will
This Living Will is designed in accordance with the New York Health Care Agents and Proxies Law (Article 29-C of the New York State Public Health Law). It provides a way for individuals to communicate their wishes regarding medical treatment in situations where they are unable to make decisions for themselves.
Personal Information
Full Legal Name: ___________________________________________
Address: ___________________________________________________
City: ____________________ State: NY Zip Code: ______________
Date of Birth: ________________ Telephone Number: ____________
Email Address: _____________________________________________
Declaration
I, __________________________ (insert full legal name), being of sound mind and not under duress, fraud, or undue influence, do hereby declare my wishes concerning medical treatment. These wishes are to be followed if I am unable to communicate or make decisions regarding my medical care.
Treatment Preferences
Please initial next to your choices to indicate your treatment preferences:
- _____ I wish to receive all forms of life-sustaining treatment, including mechanically provided nutrition and hydration (feeding tubes).
- _____ I wish to receive life-sustaining treatment, except mechanically provided nutrition and hydration (feeding tubes).
- _____ I do not wish to receive any form of life-sustaining treatment, including mechanically provided nutrition and hydration (feeding tubes).
Durable Health Care Proxy
If I am unable to make healthcare decisions for myself, I designate the following individual as my health care proxy:
Name of Health Care Proxy: ___________________________________
Relationship to Me: _________________________________________
Address: ___________________________________________________
Telephone Number: ___________________________________________
Alternate Health Care Proxy (if primary is unavailable):
Name of Alternate Health Care Proxy: ___________________________
Relationship to Me: _________________________________________
Address: ___________________________________________________
Telephone Number: ___________________________________________
Organ Donation
I wish to make an organ donation upon my death:
- _____ Yes, I wish to donate any needed organs or tissues.
- _____ Yes, but only the following organs or tissues: _______________.
- _____ No, I do not wish to donate my organs or tissues.
Signature
This document, understood by me, is signed in the presence of witnesses on this day:
Date: ___________________________
Signature: ________________________
Witness Declaration
We, the undersigned witnesses, declare that the declarant is known to us, signed this document in our presence, and appears to be of sound mind and free of duress, fraud, or undue influence.
Witness 1:
Name: ___________________________
Address: ________________________
Signature: _______________________
Date: ___________________________
Witness 2:
Name: ___________________________
Address: ________________________
Signature: _______________________
Date: ___________________________