New York Living Will (Page 2 of 3) in pdf

New York Living Will Page 2

as my health care agent to make all health care decisions for me in conformity with the guidelines I

have expressed in this document. I direct my agent to make health care decisions in accordance

with my wishes and instructions as stated above or as otherwise known to him or her. I also direct

my agent to abide by any limitations on his or her authority as stated above or as otherwise known

to him or her.

2. In the event my health care agent is unable, unwilling, or unavailable to serve as such, then I

appoint as my substitute health care agent (with the same powers that I have heretofore

enumerated).

Name:

Address:

Phone Number:

I understand that unless I revoke it, this living will and health care proxy will remain in effect

indefinitely.

These directions express my legal right to refuse treatment, under the laws of New York. Unless I

have revoked this instrument or otherwise clearly and explicitly indicated that I have changed my

mind, it is my unequivocal intent that my instructions as set forth in this document be faithfully

carried out.

Signature:

Address:

Date:

Statement By Witnesses (Must Be 18 or Older)

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.

Witness:

New York Living Will Page 2