New York Living Will
This Living Will is made in accordance with the laws of the State of New York. It is intended to set forth my wishes regarding medical treatment in the event that I become unable to communicate my decisions.
Personal Information
- Full Name: _____________________________
- Date of Birth: _____________________________
- Address: ________________________________
- Phone Number: ___________________________
I, _______________________________ (your name), being of sound mind, hereby make this declaration regarding my medical treatment in the event that I am unable to make my own decisions regarding such treatment.
Medical Treatment Preferences
- If I am in a terminal condition and there is no reasonable expectation of recovery, I do not wish to receive life-sustaining treatment.
- If I am in a persistent vegetative state and there is no reasonable expectation of recovery, I do not wish to receive life-sustaining treatment.
- Under the following conditions, I do not wish to receive treatment that would prolong my life:
- ________________
- ________________
- ________________
This Living Will expresses my wishes regarding medical treatments to be provided or withheld. It supersedes any previous Living Wills or similar documents.
Designation of Healthcare Proxy
I designate the following person as my healthcare proxy:
- Name: _____________________________
- Relationship: ________________________________
- Phone Number: ___________________________
Signature
By signing below, I affirm that I am of sound mind and that this document reflects my wishes.
- Signature: _____________________________
- Date: ________________________________
Witnesses
This Living Will must be witnessed by two individuals who are not named in this document:
- Witness 1 Name: _____________________________
- Witness 1 Signature: ________________________
- Date: ________________________________
- Witness 2 Name: _____________________________
- Witness 2 Signature: ________________________
- Date: ________________________________
Please keep this document in a safe place and provide copies to your healthcare proxy and family members.