Fillable Printable Durable Power of Attorney for Medical Treatment - New York

Durable Power of Attorney for Medical Treatment - New York

STATE OF NEW YORK

DURABLE POWER OF ATTORNEY FOR MEDICAL TREATMENT

I, , having an address at , appoint having an address at as myattorney-

in-facttocarryoutmyspecificandgeneralinstructionsandwisheswithrespecttoandall

medical treatment.

IntheeventthepersonIappointisunable,unwillingorunavailabletoactasmyhealthcare

agent, I hereby appoint having an address at

Ihavemadeknowntomyattorney-in-factandauthorizehim/hertoexpressandcarryoutmy

specificandgeneralinstructionsandwisheswithrespecttomedicaltreatment,includingmy

desiresonthesubjectofwithholdingorwithdrawingallformsoflife-sustainingmedical

treatment, including tubal feedings and medication.

ThispowerofattorneyshallbecomeeffectivewhenIcannolongermakemyownmedical

decisions and shall notbe affected bysubsequent disability or incompetence. The determination

ofwhetherIcan makemyownmedicaldecisionsis tobemadebymy attorney-in-fact,orif he

or she is unable, unwilling or unavailable to act, by my alternate attorney-in-fact.

IN WITNESS WHEREOF, I have set my hand this day of , 20 .

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principal

Theaboveprincipal,whoappearstobeofsoundmindandundernoduress,voluntarilysigned

thisinstrumentinourpresence.Iamnotthepersonappointedasattorney-in-factoralternate

attorney-in-fact by this document.

WitnessAddress

STATE OF NEW YORK

COUNTY OF , ss:

Onthe day of ,inthe year20 ,before metheundersigned, personally

appeared personally known to me or proved to me on the basis of satisfactory evidence, to

be the individual(s) whose name(s) is (are) subscribed to the within instrument and

acknowledgedtomethat(he)(she)(they)executedthesamein(his)(her)(their)capacity(y)

(ies), and that by(his) (her) (their) signature(s) onthe instrument, the individual(s)or the person

upon behalf of which the individual(s) acted, executed the instrument.

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Notary Public