New York Living Will Template
This Living Will template is created in accordance with New York state laws governing healthcare decisions.
By completing this document, you are expressing your wishes about medical treatment in the event you become unable to communicate those wishes yourself. Ensure that your preferences are discussed with your healthcare provider and family members.
PART 1: Personal Information
- Full Name: ____________________________________
- Date of Birth: __________________________________
- Address: ______________________________________
- Phone Number: _________________________________
- Email Address: ________________________________
PART 2: Living Will Declaration
I, the undersigned, willingly make this declaration concerning my healthcare choices and preferences. This Living Will reflects my wishes regarding medical treatment when I am unable to communicate my decisions due to incapacity.
PART 3: Treatment Preferences
Please indicate your choices for the following situations:
- In the event of a terminal illness or condition:
- [ ] I wish to receive all possible medical treatment.
- [ ] I do not wish to receive treatment that only prolongs the dying process.
- If I am in a persistent vegetative state:
- [ ] I wish to receive life-sustaining treatment.
- [ ] I do not wish to receive life-sustaining treatment.
- In the case of severe illness with no hope of recovery:
- [ ] I wish to be given comfort care only.
- [ ] I desire to have all medical interventions available.
PART 4: Additional Instructions or Comments
______________________________________________________________________________
______________________________________________________________________________
PART 5: Signatures
By signing below, I affirm that I understand the content of this Living Will and that it reflects my wishes regarding my medical treatment.
Signature: _____________________________________
Date: _________________________________________
Witness 1: ____________________________________
Date: _________________________________________
Witness 2: ____________________________________
Date: _________________________________________
Ensure this document is shared with your healthcare provider and stored in an accessible place.