Fillable Vermont Advance Directive For Health Care (Page 6 of 8) in pdf

Vermont Advance Directive For Health Care Page 6

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ADVANCE DIRECTIVE, PAGE 4

NAME _________________________________________________________________________ DOB ______________________ DATE __________________

Additional Limitations of Treatment I wish to include:

: o

& B

art

our

rgan

issuE

onation

urial

isposition

Emains

My wishes for organ & tissue donation (check your choice(s)):

I consent to donate the following organs & tissues:

Any needed organs

Any needed tissue (skin, bone, cornea)

I do not wish to donate the following organs and tissues:

__________________________________________________

I do not want to donate any organs or tissues

I want my health care agent to decide

I wish to donate my body to research or educational program(s). (Note: you will have to make your

own arrangements with a medical school or other program in advance.)

My Directions for Burial/Disposition of My Remains after I Die (please check & complete):

I have a Pre-Need Contract for Funeral Arrangements:

NAME __________________________________________________________________________________________ PHONE _________________________________

ADDRESS _____________________________________________________________________________________________________________________________________

I want the following individuals to decide about my burial or disposition of my remains (check choices):

Agent

Alternate Agent

Family:

NAME __________________________________________________________________________________________PHONE __________________________________

ADDRESS _____________________________________________________________________________________________________________________________________

Other:

NAME _________________________________________________________________________________________ PHONE __________________________________

ADDRESS _____________________________________________________________________________________________________________________________________

Specific Wishes: Check your choice(s).

I want a wake/Viewing

I prefer a Burial — If possible at the following location: (cemetery, address, phone number)

______________________________________________________________________________________________________________________________________________

I prefer Cremation — with my ashes kept or scattered as follows:

______________________________________________________________________________________________________________________________________________

(PART FOuR CONTINuED NExT PAGE)

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Vermont Advance Directive For Health Care Page 6

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