New Jersey Advance Directive For Health Care (Living Will) (Page 6 of 7) in pdf

Durable Power of Attorney for Health Care for the Appointment of a Health Care Representative

(Proxy Directive)

*** I____________________________________________ (print name here) do hereby

appoint:

(Name)______________________________________(City)_______________(State)________

(Zip)___________

to be my health care representative to make any and all health care decisions for me, including

decisions to accept or to refuse any treatment, service or procedure used to diagnose or treat my

physical or mental condition and decisions to provide, withhold or withdraw life-sustaining

treatment if I am unable to make such decision myself. I direct my health care representative to

make decisions on my behalf in accordance with my wishes as stated in this document, or as

otherwise known to him or her. In the event my wishes are not clear or if a situation arises that I

did not anticipate my health care representative is authorized to make decisions in my best

interest.

If the previously named person is unable, unwilling, or unavailable to act as my health care

representative, I appoint the following as my alternate health care representative:

Name ________________________________________

Telephone ____________________

Address ______________________________________________________________________

City _________________________ State ______ Zip Code ____________________________

I sign this document knowingly and after careful deliberation this ___________ day of

____________, 20________.

** Signature ___________________________________________________________________

Address ______________________________________________________________________

City ______________________

State ___________

Zip Code ______________________

Witnesses:

Witness Signature _______________________________ Witness Name (print) _____________

Address ______________________________________________________________________

City ______________________

State ___________

Zip Code ______________________

Witness Signature _______________________________ Witness Name (print) _____________

Address ______________________________________________________________________

City ______________________

State ___________

Zip Code ______________________

Sworn and Subscribed before me on the ____________ day of ________________, 20________

_____________________________

Notary Public – State of New Jersey

New Jersey Advance Directive For Health Care (Living Will) Page 6