New York Living Will Declaration
This Living Will Declaration is made in accordance with the New York Health Care Proxy Law (Article 29-C of the New York State Public Health Law). It serves as a directive for the provision, withholding, or withdrawal of life-sustaining treatment and artificially provided nutrition and hydration if I am unable to make my own healthcare decisions.
Part I: Information of the Declarant
Name of Declarant: ___________________________________________
Date of Birth: ___________________
Address: _____________________________________________________
City: ___________________________ State: NY Zip: ______________
Part II: Appointment of a Health Care Agent
I, _________________________, being of sound mind, hereby designate the following individual as my Health Care Agent to make any and all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration, and any other treatments or procedures that could keep me alive, in the event I am unable to make my own health care decisions.
Name of Health Care Agent: _____________________________________
Relationship to Declarant: ____________________________________
Address: _____________________________________________________
Phone Number: ___________________ Email: ______________________
Part III: Alternate Health Care Agent (Optional)
If my Health Care Agent is unwilling, unable, or ineligible to act as my agent, I designate the following individual as my alternate Health Care Agent:
Name of Alternate Health Care Agent: ____________________________
Relationship to Declarant: _____________________________________
Address: ______________________________________________________
Phone Number: __________________ Email: _______________________
Part IV: Directions Regarding Health Care
- I do not want life-sustaining treatment if I am in a terminal condition, in a permanent coma, or in a persistent vegetative state with no reasonable expectation of recovery.
- I do not want to receive artificially provided fluids and nutrition.
- I wish to receive all possible treatments to extend my life for as long as possible within the limits of generally accepted health care standards.
- Other directions: __________________________________________________________
Part V: Organ and Tissue Donation (Optional)
I wish to donate only the following organs or tissues: ______________________________
I wish to donate any needed organs or tissues.
I do not wish to make an organ or tissue donation.
Part VI: Signature
I understand the contents of this document and I declare that I am emotionally and mentally competent to make this Living Will. This Living Will represents my wishes as to my health care. It revokes any prior Living Will that I have made.
Signature of Declarant: ______________________________________ Date: ______________
Print Name: __________________________________________________
Part VII: Witness Affirmation
Two adult witnesses must sign below, affirming that the declarant is known to them, signed this document in their presence, and appears to be of sound mind and not under duress, fraud, or undue influence.
Witness 1 Signature: ________________________________________ Date: ______________
Print Name: __________________________________________________
Witness 2 Signature: ________________________________________ Date: ______________
Print Name: __________________________________________________