New Jersey Living Will
This Living Will is made in accordance with the laws of the State of New Jersey. It signifies my preferences regarding medical treatment in the event that I become unable to communicate my wishes concerning my healthcare.
Personal Information:
- Full Name: ____________________________________
- Date of Birth: __________________________________
- Address: ______________________________________
- City: __________________________________________
- State: NJ
- Zip Code: ______________________________________
Appointment of Healthcare Representative:
I hereby appoint the following individual as my healthcare representative:
- Name: _________________________________________
- Relationship: _________________________________
- Phone Number: ________________________________
- Email Address: ________________________________
Preferences for Medical Treatment:
If I am diagnosed with a terminal illness, or if I am in a permanent unconscious state, I make these specific wishes regarding my medical treatment:
- □ I wish to receive all treatment necessary to prolong my life, even if it may cause discomfort.
- □ I prefer not to receive life-sustaining treatment if it only prolongs the dying process.
- □ I wish to receive palliative care to alleviate pain and improve comfort.
- □ Additional instructions: ___________________________________
Signature:
By signing this Living Will, I confirm that I understand its contents and that I am doing so voluntarily:
- Signature: ____________________________________
- Date: _________________________________________
Witnesses:
This document must be witnessed by two individuals who are not related to me and who will not inherit from me:
- Witness 1 Name: ________________________________
- Witness 1 Signature: ___________________________
- Witness 1 Date: ________________________________
- Witness 2 Name: ________________________________
- Witness 2 Signature: ___________________________
- Witness 2 Date: ________________________________
Please ensure that copies of this Living Will are provided to my healthcare representative, family members, and any relevant healthcare providers.