Health Care Proxy - New York Department Of Health (Page 2 of 2) in pdf

Health Care Proxy - New York Department Of Health Page 2

(5) Your Identiﬁcation (please print)

Your Name ___________________________________________________________________________

Your Signature _________________________________________________ Date ________________

Your Address __________________________________________________________________________

(6) Optional: Organ and/or Tissue Donation

I hereby make an anatomical gift, to be effective upon my death, of:

(check any that apply)

■

Any needed organs and/or tissues

■

The following organs and/or tissues ____________________________________________________

___________________________________________________________________________________

■

Limitations ________________________________________________________________________

If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will

not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise

authorized by law, to consent to a donation on your behalf.

Your Signature ___________________________ Date _______________________________________

(7) 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 ____________________________________ Date _______________________________________

Name of Witness 1

Name of Witness 2

(print) __________________________________ (print) _____________________________________

Signature _______________________________ Signature __________________________________

Address _________________________________ Address ____________________________________

________________________________________ ___________________________________________

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Health Care Proxy - New York Department Of Health Page 2