This form is intended as a SAMPLE only.  The form below is a variation of the standard New York form.  Do not use this form without consulting experienced counsel.

    To My Family, Doctors, and All Those Concerned with My Care I,_____________

________________________ being of sound mind, make this statement as a directive to be followed and shall take effect in the event I become unable, to a reasonable degree of medical certainty, to make my own health care decisions or communicate instructions in addition to those herein stated.

I designate the following person to act as my health care agent with the intent that (s)he shall make any and all health care decisions on my behalf, except to the extent I state otherwise:

Name:

Address:

If the person I have named above is unable to act on my behalf, I authorize the following person to do so:

Name:

Address:

It is my intention that my health care agent shall have [shall not have] the authority, in addition to other authority hereby granted to direct my doctors to withdraw artificial nutrition and hydration.

I direct my agent to make health care decisions in accordance with these instructions and my wishes as stated above and in accord with my wishes otherwise made known to my agent, whether or not expressed in a "Living Will" or other type of advance directive.

These directions express my legal right to refuse treatment. Therefore I expect my family, doctors, and everyone concerned with my care to regard themselves as

legally and morally bound to act in accord with my wishes, and in so doing to be free of any legal liability for having followed my directions.

I especially do not want to be kept alive artificially when I have no prospect for a recovery such that I would be able to have a meaningful life. I therefore do not want to be dependent upon feeding tubes, respirators or ventilators, for example, when such treatments only prolong my dying, and I hereby direct that my agent has the specific authority to cause a notice to be placed on my hospital chart, pursuant to Article 29_B of the Public Health Law of the State of New York, as now enacted or hereafter amended,  not to resuscitate me if such agent believes that I would want such an order to be included on my chart.

OTHER INSTRUCTIONS:

I understand that unless I revoke this proxy, this proxy will remain in effect indefinitely.

Date:

                                                                                ______________________________L.S.

We the undersigned witnesses to the Health Care Proxy of ___________________ have hereunto subscribed our names at her request, and hereby attest that such instrument was signed willingly by ___________________ and who at the time of so signing was, in the opinion of the undersigned, free from duress.

WITNESSES

____________________________

____________________________