New Jersey Living Will
This Living Will is executed pursuant to the New Jersey Adult Medical Day Care and Health Care Proxy Act. It reflects my wishes regarding medical treatment in the event that I am unable to communicate my preferences.
Personal Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City, State, Zip: ____________________
- Phone Number: ______________________
Directive: In the event that I am diagnosed with a terminal condition or am in a persistent vegetative state, I request the following:
- I do not wish to receive life-sustaining treatment if it only prolongs the dying process.
- I would like to receive humanitarian care to ensure comfort and dignity.
- If I am unable to swallow, I do not want artificial nutrition or hydration.
Optional Designation of Health Care Proxy:
I appoint the following individual as my health care proxy to make decisions regarding my medical care if I am unable to do so:
- Name: ______________________________
- Relationship: ______________________
- Phone Number: ______________________
Signature:
I hereby declare that I am of sound mind and that I execute this Living Will voluntarily:
- Signature: __________________________
- Date: ______________________________
Witness:
My signature must be witnessed by two individuals who are not related to me and do not stand to inherit from me:
- Witness Name: ______________________
- Witness Signature: _________________
- Date: ______________________________
- Witness Name: ______________________
- Witness Signature: _________________
- Date: ______________________________
This Living Will is designed to guide my health care decisions in accordance with my personal values and preferences.