New Jersey Durable Power Of Attorney For Health Care Will To Live Form printable pdf download

New Jersey Durable Power Of Attorney For Health Care Will To Live Form

New Jersey Durable Power of Attorney for Health Care

Will to Live Form

I, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

designate_____________________________________________________________________

(Name of health care representative)________________________________________________

(address)______________________________________________________________________

(phone number(s))_______________________________________________________________

as my health care representative to make any health care decisions for me as authorized in this

declaration consistent with the instructions below.

If the person I designate above refuses or is not able to act for me, I designate the following

persons (each to act alone and successively, in the order named):

A. First Successor Health Care Representative

(successor’s name)______________________________________________________________

(successor’s address)_____________________________________________________________

______________________________________________________________________________

(successor’s phone number)_______________________________________________________

B. Second Successor Health Care Representative

(second successor’s name)________________________________________________________

(second successor’s address)______________________________________________________

______________________________________________________________________________

(second successor agent’s phone number)____________________________________________

as my health care representative to make any health care decisions for me as authorized in this

document consistent with the instructions below.

This designation shall become effective only when I become incapable of making my own health

care decisions.

Any prior designation or other advance directive for health care is revoked.

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New Jersey Durable Power Of Attorney For Health Care Will To Live Form