New York Living Will
This Living Will is created in accordance with the New York State laws regarding health care decisions.
Patient Information:
- Name: ___________________________
- Date of Birth: ____________________
Declaration:
I, the undersigned, being of sound mind, do hereby declare this to be my Living Will. I wish to make known my wishes regarding medical treatment in the event that I am unable to communicate my preferences.
Medical Preferences:
- If I am diagnosed with a terminal illness or a condition that will result in my death, I do not wish to receive the following treatments:
- Cardiopulmonary resuscitation (CPR)
- Mechanical ventilation
- Artificial nutrition and hydration
- If I am in a persistent vegetative state, I do not wish to receive life-sustaining treatment.
- I wish to receive comfort care, including pain relief, even if it may hasten my death.
Appointment of Health Care Agent:
I hereby appoint the following individual as my health care agent to make health care decisions on my behalf if I am unable to do so:
- Name: ___________________________
- Relationship: _____________________
- Address: _________________________
- Phone Number: ____________________
Signature:
By signing below, I affirm that I am of sound mind and that this document reflects my wishes regarding medical treatment.
Signature: ___________________________
Date: ________________________________
Witnesses:
This Living Will must be witnessed by at least two individuals who are not related to me and who are not entitled to any part of my estate.
- Witness 1 Name: ____________________
- Witness 1 Signature: _______________
- Witness 2 Name: ____________________
- Witness 2 Signature: _______________