New York State Health Care Proxy Form

I, __________________________________________________________

hereby appoint

__________________

(name)

__________________

(address)

__________________

(city, state, zip)

__________________

(home phone) (work phone)

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 only when and if I become unable to make my own health care decisions.

2. Optional: Alternate Agent

If the person I appoint is unable, unwilling, or unavailable to act as my health care agent, I hereby appoint

__________________

(name)

__________________

(address)

__________________

(city, state, zip)

__________________

(home phone) (work phone)

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

Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in effect indefinitely. (Optional: If you want this proxy to expire, state the date or conditions here.) This proxy shall expire (specify date or conditions):

________________________________________________________________

OPTIONAL: I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below. (If you want to limit your agent's authority to make health care decisions for you or to give specific instructions, you may state your wishes or limitations here.) I direct my agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional pages as necessary):

________________________________________________________________

In order for your agent to make health care decisions for you about artificial nutrition and hydration (nourishment and water provided by feeding tube and intravenous line), your agent must reasonably know your wishes. You can either tell your agent what your wishes are or include them in this section directly above.

Your Identification (please print)

Your Name: __________________

Your Signature: __________________

Date: _ __________________

Your Address: __________________

_______ __________________

Optional: Organ and/or Tissue Donation

I hereby make an anatomical gift, to be effective upon my death, of (check any that apply):

Any needed organs and/or tissues: ____________________

The following organs and/or tissues: __________________________________

________________________________________________________________

More on this topic

________________________________________________________________

Limitations: ______________________________________________________

________________________________________________________________

If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.

Your Signature: __________ Date: __________________

Statement by Witnesses (witnesses must be 18 years of age or older and cannot be the health care agent or alternate)

Date: __________ Date: __________

Name of Witness 1 Name of Witness 2

_________________________ _________________________

(print name) (print name)

_________________________ _________________________

(signature) (signature)

_________________________ _________________________

(address) (address)

_________________________ _________________________

(city, state, zip) (city, state, zip)