Proxy Directive (Durable Power Of Attorney For Health Care ) (Page 2 of 2) in pdf

The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care

(If you have any additional specific instructions concerning your care you may use the space below or attach an

additional statement.)

___________________________________________________________________________________________

D) COPIES: The original or a copy of this document has been given to my health care representative and to the

following:

1. name ___________________________________

address _________________________________

city ________________________ state _______

telephone __________________________

2. name ___________________________________

address _________________________________

city ________________________ state _______

telephone __________________________

E) SIGNATURE: By writing this durable power of attorney for health care, I inform those who may become

entrusted with my care of my health care wishes and intend to ease the burdens of decision making which this

responsibility may impose. I have discussed the terms of this designation with my health care representative and

he or she has willingly agreed to accept the responsibility for acting on my behalf in accordance with my wishes

as expressed in this document. I understand the purpose and effect of this document and sign it knowingly,

voluntarily and after careful deliberation.

Signed this _____________ day of ______________, 20______.

signature _____________________________________________

address ______________________________________________

city ____________________________________ state_________

F) WITNESSES: I declare that the person who signed this document, or asked another to sign this document on

his or her behalf, did so in my presence, that he or she is personally known to me, and that he or she appears to be

of sound mind and free of duress or undue influence. I am 18 years of age or older, and am not designated by this

or any other document as the person’s health care representative, nor as an alternate health care representative.

1. witness____________________________________

2. witness _______________________________

address ___________________________________

address ______________________________

city _______________________ state __________

city ____________________ state _________

signature _________________________________

signature _____________________________

date ______________________________________

date _________________________________

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Proxy Directive (Durable Power Of Attorney For Health Care ) Page 2