New York Living Will Template
This Living Will is created under the laws of the State of New York. It outlines your wishes regarding medical treatment in the event you are unable to communicate your preferences.
Personal Information:
- Name: _________________________
- Date of Birth: __________________
- Address: ______________________
- City, State, Zip: _______________
- Phone Number: _________________
Healthcare Agent Information:
- Name: _________________________
- Address: ______________________
- City, State, Zip: _______________
- Phone Number: _________________
Wishes Regarding Medical Treatment:
If I am in a terminal condition or a persistent vegetative state, I wish to be treated as follows:
- For life-sustaining treatment: YES / NO
- For pain relief and comfort care: YES / NO
- For nutrition and hydration: YES / NO
Additional Instructions:
______________________________________________________________________
______________________________________________________________________
Signatures:
By signing below, I affirm that this Living Will reflects my wishes.
- Signature: ________________________
- Date: ____________________________
Witness Information:
- Name: _________________________
- Signature: _____________________
- Date: __________________________
Notary Acknowledgment:
State of New York, County of ________________:
On this ______ day of ______________, 20___, before me, a Notary Public,
personally appeared ____________________________________________.
______________________________
Notary Public Signature