New York Living Will (Page 2 of 2) in pdf

New York Living Will Page 2

These directions express my legal right to refuse treatment, under the law of New

York. I intend my instructions to be carried out unless I have rescinded them in a new

writing or by clearly indicating that I have changed my mind.

Signed: ______________________________________ Date: _______________

Statement by Witnesses (Witnesses must be 18 years of age or older

and cannot be the health care agent or alternate.)

I declare that the person who signed this document is personally known

to me and appears to be of sound mind and acting of his or her own free

will. He or she signed (or asked another to sign for him or her) this

document in my presence.

Date:______________

Witness 1 (Signature):_____________________________________

Witness 1 (Print name):____________________________________

Witness 1 (Address):_______________________________________

________________________________________________________

Date:______________

Witness 2 (Signature):______________________________________

Witness 2 (Print name):_____________________________________

Witness 2 (Address):_______________________________________

________________________________________________________

Page 2 of 2

New York Living Will Page 2