Fillable Printable Free Living Will Forms Template

Free Living Will Forms Template

Completing Your New York Living Will

Remember the Living Will only becomes effective if you are determined to have a

terminal illness or are at the end-of-life and are unable to speak for yourself. In NYS,

the living will was authorized by the courts not by legislation so there are no

requirements guiding its use. But, a Living Will can serve an important role to provide

clear evidence of your wishes.

You can add personal instructions in Item 3 on the form if there are specific treatments

that you wish to refuse but are not listed on the document.

You can also add a statement referring to your health care agent such as, “Any

questions about how to apply my Living Will are to be decided by my health care agent.”

Print out a copy of the Living Will Form based on the form developed by the NYS

Attorney General.

Item 1: Print your name

Item 2: Cross out any of the statements that do NOT reflect your wishes

Item 3: Write in any personal instructions

Item 4: Date and sign the document and include your address

Item 5: Two witnesses must sign the document and print their addresses.

Note: This form does not need to be notarized.

NEW YORK LIVING WILL

This Living Will has been prepared to conform to the law in the State of New York, as set forth in the case

In re Westchester County Medical Center, 72 N.Y. 2d 517 (1988). In that case the Court established the

need for “clear and convincing” evidence of a patient's wishes and stated that the“ideal situation is one in

which the patient's wishes were expressed in some form of writing, perhaps a ‘Living Will’.”

I, [1]______________________________________________, being of sound

mind, make this statement as a directive to be followed if I become

permanently unable to participate in decisions regarding my medical care.

These instructions reflect my firm and settled commitment to decline

medical treatment under the circumstances indicated below:

I direct my attending physician to withhold or withdraw treatment that

merely prolongs my dying, if I should be in an incurable or irreversible

mental or physical condition with no reasonable expectation of recovery,

including but not limited to: (a) a terminal condition; (b) a permanently

unconscious condition; or (c) a minimally conscious condition in which I

am permanently unable to make decisions or express my wishes.

I direct that my treatment be limited to measures to keep me comfortable

and to relieve pain, including any pain that might occur by withholding or

withdrawing treatment. While I understand that I am not legally required

to be specific about future treatments if I am in the condition(s) described

above I feel especially strongly about the following forms of treatment:

[2]

I do not want cardiac resuscitation.

I do not want mechanical respiration.

I do not want artificial nutrition and hydration.

I do not want antibiotics.

However, I do want maximum pain relief, even if it may hasten my death.

[3] Other directions:

These directions express my legal right to refuse treatment, under the law

of New York. I intend my instructions to be carried out, unless I have

rescinded them in a new writing or by clearly indicating that I have

changed my mind.

[4]

Signed ____________________________________ Date_________________

Address___________________________________________________________

I declare that the person who signed this document appeared to execute

the Living Will willingly and free from duress. He or she signed (or asked

another to sign for him or her) this document in my presence.

[5]

Name of Witness 1 (please print, sign and date)

_____________________________________________Date _________________

Address___________________________________________________________

Name of Witness 2

_____________________________________________ Date_________________

Address___________________________________________________________