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95Health care proxy with living will directives, PHL 2980, 7-94
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E
(with living will directives)
I
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I .................................................................................................................................... hereby appoint
Person giving this proxy
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P
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Name of agent
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Home address
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Telephone number of agent
W
E
as my health care agent to make any and all health care decisions for me, except to the extent
I state otherwise.
I
V
This health care proxy shall take effect in the event I become unable to make my own
health care decisions.
NOTE: Although not necessary, and neither encouraged nor discouraged, you may wish
to state instructions or wishes, and limit your agent's authority. Unless your agent knows your
wishes about artificial nutrition and hydration, your agent will not have authority to decide
about artificial nutrition and hydration. If you choose to state instructions, wishes, or limits,
please do so below:
E
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P
If a situation should arise in which there is no reasonable expectation for 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, life support equipment 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 statement is made after careful consideration and is in accordance with my convictions
and beliefs. I urge those concerned to take whatever action necessary, including legal action,
to fulfill my wishes and directions.
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I additionally direct the following by checking the box and writing my initials next to
the desired provisions.
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1.
I do not wish artificial nutrition.
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2.
I do not wish artificial hydration.
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3.
I wish to live out my last days at home rather than in a hospital if it does not
jeopardize the chance of my recovery to a meaningful and conscious life and
does not impose an undue burden on my family.
E
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P
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4.
If any of my tissues or organs are sound and would be of value as transplants
to other people, I freely give my permission for such donations.
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5.
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I DIRECT MY AGENT to make health care decisions in accordance with my wishes and
instructions as stated above or as otherwise known to him or her. I also direct my agent to abide
by any limitations on his or her authority as stated above or as otherwise known to him or her.
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In the event the person I appoint above is unable, unwilling or unavailable to act as my
health care agent, I hereby appoint
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........................................................................................................................
Name of agent
........................................................................................................................
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Home address
........................................................................................................................
........................................................................................................................
Telephone number of alternate agent
E
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as my health care agent.
I UNDERSTAND THAT, unless I revoke it, this will remain in effect indefinitely or
until the date or occurrence of the condition I have stated below:
Please complete the following if you DO NOT want this health care proxy to be in effect
indefinitely:
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This proxy shall expire: ........................................................................................................................
Specify date or condition
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.......................................................................................................... ................................
Date
..........................................................................................................
Address
..........................................................................................................
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I DECLARE THAT the person who signed or asked another to sign this document is
personally known to me and appears to be of sound mind and acting willingly and free from
duress. He or she signed (or asked another to sign for him or her) this document in my presence
and that person signed in my presence. I am not the person appointed as agent by this document.
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Date
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Signature
Signature
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Print name
....................................................................
Address
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...................................................................
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Date
Print name
Zip Code
Telephone
Address
Zip Code
Telephone
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I
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E
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New York State PHL 2980
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....................................
Date of proxy
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.............................................................................................
Person giving proxy
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(with living will directives)
PUBLISHED BY
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Agent
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Afternate Agent
The publisher maintains property rights in the layout, graphic design and typestyle of this form as well as in the company's
trademarked logo and name. Reproduction of blank copies of this form without the publisher's permission is prohibited. However,
once a form has been filled in, photocopying is permitted.
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