New York Health Care Proxy Form Page 2

(5)

Your Identification (please print)

Your Name:

Your Signature:

Date:

Your Address:

(6)

Optional: Organ and/or Tissue Donation

Upon my death, I wish to donate my organs, tissues or body parts:

(check any that apply and note limitations)

_____ Any needed organs and/or tissues

_____ Only the following organs and/or tissues:

My donation is for the following:

___transplant ___therapy ___research ___education ___any use

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 known to me and

appears to execute this proxy willingly and 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.

Name of Witness 1 (please print):

Date:

Signature:

Address:

Name of Witness 2 (please print):

Date:

Signature:

Address :

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Parent category: Medical