Living Will and Health Care Proxy of
TO MY FAMILY, MY PHYSICIANS, ANY MEDICAL FACILITY HAVING RESPONSIBILITY FOR MY CARE, AND ALL OTHERS CONCERNED WITH MY WELLBEING OR AFFAIRS: I, , hereby appoint , residing at , and whose telephone number is , as my health care agent to make any and all health care decisions for me, except to the extent I state otherwise. In the event I receive care in a nursing facility, my health care agent shall also act as my designated representative as defined in 10 NYCRR ' 415.2(f). My health care agent will receive information when my nursing facility is required to provide information to both myself and a designated representative and also receive information if I become unable to understand such information. My health care agent will participate, to the extent authorized under State law, in decisions regarding my care, treatment and well-being. This health care proxy shall take effect in the event I become unable to make my own health care decisions, except that the provisions in the immediately preceding paragraph appointing my health care agent to act as my designated representative in the event I receive care in a nursing facility shall take effect immediately. Without limiting in any way the authority of my health care agent, I wish to state my instructions concerning the withdrawal or withholding of life-sustaining treatment. These instructions shall apply whether or not my health care agent is living and able to carry them out. If the situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability, I direct that I be allowed to die and not be kept alive by medications, artificial means of nutrition, hydration or respiration, or other artificial means or "heroic measures". I do, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life. This request is made after careful consideration and is in accordance with my strong convictions and beliefs. In the absence of my ability to give directions regarding the use of life-sustaining treatments as described above, it is my intention that this directive shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
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I direct my health care agent to make health care decisions in accordance with my wishes and instructions as stated above, or as otherwise known to my health care agent. I also direct my health care agent to abide by any limitations on my health care agent's authority as stated above or as otherwise known to my health care agent. If my health care agent named above is unable to act, then I appoint the following individuals, acting successively in the following order of priority, as my health care agent, each one of them to serve in the event all those named before such individual are unable to act: 1. 2. , residing at , residing at , and whose telephone number is , and whose telephone number is ; and .
I request, but do not direct, that, to the extent possible and convenient, my then acting health care agent shall consult with all of the individuals named herein as successor health care agents in making any such decision, provided that in the event of a disagreement the decision of my then acting health care agent shall govern and be binding and conclusive upon all persons affected by such decision, and I further request that a copy of this instrument be provided to such person in the event I become unable to make my own health care decisions. I understand that, unless I revoke it, this proxy will remain in effect indefinitely. IN WITNESS WHEREOF, I have signed this instrument on Signature: .
Residing at: I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting willingly and free from duress. Such person signed this document in my presence. I am not the person appointed as agent by this document. Witnesses: residing at
residing at
State of New York County of
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ss.:
On the day of in the year 20____ before me, the undersigned, a Notary Public in and for said State, personally appeared ________________ , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument.
Notary Public