New York State Health Care Proxy Form

1. I, ____________________________________________________________ hereby appoint

____________________________________________________________

(name, home address and telephone number)

as my health care agent to make any and all health care decisions for me, except to the extent that

I state otherwise. This proxy shall take effect when and if I become unable to make my own

health care decisions.

2. Optional instructions: I direct my agent to make health care decisions in accord with my wishes and

your agent will not be allowed to make decisions about artificial nutrition and hydration.

See instructions on reverse for samples of language you could use.)

3. Name of substitute or fill-in-agent if the person I appoint above is unable, unwilling or

unavailable to act as my health care agent.

______________________________________________________________________________

(name, home address and telephone number)

______________________________________________________________________________

4. Unless I revoke it, this proxy shall remain in effect indefinitely, or until the date or conditions

stated below. This proxy shall expire (specific date or conditions, if desired):

of sound mind and acting 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.

Witness 1 _____________________________________________________________________

Address ______________________________________________________________________

Witness 2 _____________________________________________________________________

Address_______________________________________________________________________