New York Health Care Proxy

After (1) I, write your name, then the agent's Name, Home Address and Telephone Numbers.

This proxy takes effect only when and if you become unable to make your own health care decisions.

Optional: if the person you appoint is unable, unwilling or unavailable to act as your health care agent, write the Alternate's Name, Home Address and Telephone Numbers.

Unless you revoke it, this proxy remains in effect indefinitely or until the date or condition you have stated. Optional: if you want this proxy to expire, state the date or conditions here.

Optional Instructions: you direct your agent to make health decisions in accordance with your wishes and limitations as stated here, or as he or she otherwise knows. Attach additional pages as necessary.

The form prints: "My agent knows my wishes regarding artificial nutrition and hydration."

Under (5) Your Identification (please print), write Your Name, Your Signature, the Date and Your Address.

Optional: Organ and/or Tissue Donation. Upon your death, you wish to donate your organs, tissues or body parts: check any that apply and note limitations.

Check Any needed organs and/or tissues, or check Only the following organs and/or tissues and list them.

Under My donation is for the following, check transplant, therapy, research, education or any use.

Write Your Signature and the Date.

Statement by Witnesses: "I declare that the person who signed this document is known to me and appears to execute this proxy willingly and of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence."

For Witness 1 and Witness 2, write the Name (please print), Date, Signature and Address.

You can appoint an alternate: if the person you appoint is unable, unwilling or unavailable to act as your health care agent, you appoint the alternate.