New Jersey Living Will And Health Care Surrogate Declaration (Page 2 of 2) in pdf

New Jersey Living Will And Health Care Surrogate Declaration Page 2

Alternate:

Name

Address

Phone

I understand the full import of this declaration, and I am emotionally and mentally

competent to make this declaration.

Declarant’s Signature

# 1 Witness Signature

Address

# 2 Witness Signature

Address

Before me, on this ____ day of _________ 20___ , personally appeared :

Declarant

whose

I.D. is

#1Witness

whose

I.D. is

#2Witness

whose

I.D. is

to be the Declarant and Witnesses, respectfully, whose names are signed to the forgoing

instrument, and who, in the presence of each other, did freely subscribe their names to the

Declaration (Living Will) on this date, and that each was over the age of majority and of

sound mind, and the witnesses do attest and affirm that the Declarant is of sound mind

and free of duress and undue influence.

Neither witness is named as Declarant’s

designated health care representative.

______________________________________

My Commission Expires:

Notary Public

America Living Will Registry, LLC. • 2814 Beach Boulevard • St. Petersburg, FL 33707 • 1-866-305-ALWR •

New Jersey Living Will And Health Care Surrogate Declaration Page 2