New Jersey Living Will
This Living Will is made in accordance with the laws of the State of New Jersey. It expresses my wishes regarding medical treatment and end-of-life care.
Personal Information
- Full Name: _________________________________
- Date of Birth: _____________________________
- Address: ______________________________________
- City: ______________________________________
- State: _____________________________________
- Zip Code: _________________________________
Declaration
I, the undersigned, hereby declare that if I am unable to communicate my wishes regarding medical treatment due to illness or injury, this document serves as my Living Will.
Medical Treatment Preferences
Please indicate your preferences regarding the following treatments:
- Life-Sustaining Treatment: Do you want life-sustaining treatment if you are terminally ill or permanently unconscious? (Yes/No): ______________
- Comfort Care: Do you wish to receive comfort care, including pain relief and sedation? (Yes/No): ______________
- Nutrition and Hydration: Do you want to receive artificial nutrition and hydration? (Yes/No): ______________
Designation of Health Care Representative
I designate the following person to make health care decisions on my behalf if I am unable to do so:
- Name: ___________________________________________
- Relationship: ____________________________________
- Phone Number: ___________________________________
Signature
By signing below, I confirm that I am of sound mind and that this Living Will reflects my wishes:
Signature: ________________________________________
Date: _____________________________________________